A 78-year-old patient with a fractured hip is scheduled for surgery tomorrow morning. Which nursing intervention is the HIGHEST priority to prevent complications during the preoperative period?

Strict bed rest prevents fracture displacement, which could cause severe vascular or nerve damage. Other interventions (position changes, ice, ambulation) are important but secondary to immobilization.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient with a hip fracture in the preoperative period. The core principle is Key Point! immobilization of the fracture site to prevent further injury. An unstable hip fracture can cause sharp bone fragments to lacerate nearby blood vessels (like the femoral artery) or nerves, leading to catastrophic complications such as hemorrhage, compartment syndrome, or permanent nerve damage. Therefore, maintaining alignment and preventing movement is the paramount safety concern before surgical fixation.

Answer Rationale: Option ②, "Maintain strict bed rest and avoid moving the affected leg," is correct because it directly addresses this primary safety risk. The leg is typically immobilized with traction (e.g., Buck's traction) or splinting. This intervention takes precedence over other important but secondary concerns like skin integrity, pain, or mobility.

Distractor Analysis: Watch out for confusion! The other options are all valid nursing concerns, but they are either contraindicated or lower priority preoperatively.
• Option ①: While preventing pressure ulcers is crucial, "frequent position changes" that involve moving the fractured hip are contraindicated. The nurse would focus on pressure relief for other areas (e.g., heels, sacrum) without disturbing the fracture.
• Option ③: Applying ice is appropriate for pain and swelling, but it is a comfort measure, not the highest-priority safety intervention.
• Option ④: Ambulation is absolutely contraindicated for an unstable hip fracture. Post-operative ambulation is a goal, but pre-operatively, it could cause severe displacement and injury. Preventing blood clots in this period is achieved through pharmacological prophylaxis (anticoagulants) and passive exercises, not ambulation.

Related Concepts: This question integrates principles of musculoskeletal trauma management, preoperative nursing care, and priority-setting using safety and risk frameworks (e.g., ABCs—Airway, Breathing, Circulation—where preventing hemorrhage from vessel damage falls under Circulation).

Concept Summary • Pre-op Hip Fracture Priority: Immobilization > Pain Control > Complication Prevention (DVT, skin).
• Complications of Fracture Displacement: Neurovascular injury (check pulses, sensation, movement—CMS: Circulation, Motion, Sensation), hemorrhage, increased pain.
• Post-op Priorities Shift: After internal fixation (e.g., hip pinning, replacement), early ambulation becomes a top priority to prevent pneumonia and DVT.

Side-by-Side Comparison!

Intervention	Pre-Operative Period (Unstable Fracture)	Post-Operative Period (After Fixation)
Mobility	Strict bed rest, affected leg immobilized. Traction may be used.	Early ambulation as tolerated (with walker), following weight-bearing restrictions.
Pain Management	Analgesics (IV/oral), ice packs. Avoid moving limb.	Analgesics, ice, progressive mobility to reduce pain.
DVT Prevention	Pharmacological (heparin/enoxaparin), sequential compression devices (SCDs), passive ROM exercises.	Pharmacological, SCDs, active ambulation is the best prevention.

Anatomy, Physiology & Pharmacology Points • Anatomy: The femoral artery and sciatic nerve are in close proximity to the hip joint. Fracture displacement risks damaging these structures.
• Pathophysiology: Immobilization prevents movement of bone fragments, minimizing soft tissue damage, reducing pain (from muscle spasm), and controlling bleeding.
• Pharmacology: Pre-op medications often include prophylactic anticoagulants (e.g., enoxaparin) to prevent DVT and analgesics (often opioids) for pain.
Memory Tips • Acronym: PRIORITY for Fractures: Prevent displacement -> Relieve pain -> Immobilize -> Observe neurovascular status -> Rehabilitate (post-op).
• Think "Splint First": Before you manage anything else for a traumatic fracture, you stabilize it. The same logic applies pre-op.
High-Frequency NCLEX Topics NCLEX loves testing priority-setting for unstable conditions. A hip fracture is a classic scenario. Remember: Safety and prevention of further harm always come first. An intervention that could cause injury (like ambulating) is never the right answer, no matter how beneficial it is for other reasons.
Watch Out for Question Variations! • Instead of asking for the "highest priority," it might ask: "The nurse should question which provider order?" (Answer: An order to ambulate the patient).
• It could combine with neurovascular assessment: "Which finding requires immediate intervention?" (Answer: Absent pedal pulse or loss of sensation).
• The scenario could shift to the post-operative day 1, where the priority changes to "Assist with ambulation" to prevent complications of immobility.

Nursing Clinical Practice Guide Clinical Scenario: You are assigned to Mr. Johnson, an 78-year-old admitted from the ED with a left femoral neck fracture after a fall. He is on Buck's traction, awaiting surgery in the morning. He reports pain at 7/10 and is anxious about moving.

Nursing Intervention Strategy:
1. Assessment: First, perform and document neurovascular checks (CMS) on the affected leg every 1-2 hours: Circulation (color, temperature, capillary refill, pedal pulses), Motion (ability to wiggle toes), Sensation (light touch on toes). Assess pain level and characteristics.
2. Immobilization & Safety: Ensure traction weights are hanging freely, not resting on the bed. Use a fracture bedpan. Log-roll the patient for linen changes or skin care, keeping the leg in alignment. Place a trapeze bar on the bed for the patient to move themselves without using the affected leg.
3. Complication Prevention: Apply sequential compression devices (SCDs) to the unaffected leg. Administer prescribed low-molecular-weight heparin (LMWH). Perform passive range-of-motion exercises on the unaffected limbs.
4. Pain & Education: Administer scheduled and PRN analgesics. Apply ice packs to the hip area, wrapped in a towel, for 20 minutes at a time. Explain all procedures to reduce anxiety.

Patient Safety and Precautions:
• Contraindication: Do not elevate the head of the bed more than 20-30 degrees if in traction, as this reduces its effectiveness.
• Medication Caution: LMWH injections are given subcutaneously in the abdomen. Avoid massaging the site. Monitor for signs of bleeding.
• Key Monitoring: Any change in CMS findings, sudden increase in pain, or swelling is a red flag requiring immediate notification of the surgeon.
Nursing Procedure & Medication Flow Pre-op Neurovascular Check (CMS) Procedure:
1. Explain the procedure to the patient.
2. Circulation: Palpate the dorsalis pedis and posterior tibial pulses. Compare to the unaffected side. Check capillary refill (should be < 3 seconds). Observe for pallor or cyanosis.
3. Sensation: Gently touch the top and bottom of the foot. Ask, "Can you feel this? Does it feel the same as the other foot?"
4. Motion: Ask the patient to "wiggle your toes." Do not move the limb for them.
5. Document findings clearly: "Pedal pulses 2+, cap refill 2 sec, sensation intact, toes wiggled spontaneously."
A Word from Your Senior Nurse "In the rush to manage pain or prevent a pressure ulcer, it's easy to forget the most basic rule: first, do no harm. That fractured bone is like a knife edge near major blood vessels. Your number one job before surgery is to keep it still. In clinical practice, I've seen a patient's leg turn cold and pulseless in minutes after an accidental kick against the bed rail. Those neurovascular checks aren't just a task on a list—they are your early warning system. On the NCLEX, when you see 'fracture' and 'pre-op,' let your mind scream 'IMMOBILIZE!' first. Everything else comes after."