An 82-year-old client with a fractured hip is scheduled for surgery in the morning. Which nursing intervention should be the priority during the preoperative period?

Maintaining proper alignment and immobilization is priority to prevent fragment displacement and complications like fat embolism in a hip fracture patient awaiting surgery. Other interventions are secondary.

Core Nursing Explanation Key Concept Analysis: This question assesses the nurse's ability to prioritize preoperative nursing interventions for a patient with an acute hip fracture. The core principle is the Key Point! ABCs (Airway, Breathing, Circulation) and Safety. In trauma and musculoskeletal injuries, the immediate priority is to prevent further harm. For a fractured hip, the greatest immediate risk is movement of the bone fragments, which can damage surrounding nerves, blood vessels, and tissues, increase pain, and cause life-threatening complications like fat embolism.

Answer Rationale: The correct answer is Maintain proper body alignment and immobilize the affected extremity. This is the foundational, first-step intervention. It directly addresses the primary problem: an unstable fracture. Immobilization with devices like pillows or splints prevents displacement, minimizes pain by reducing muscle spasm around the fracture site, and reduces the risk of complications such as neurovascular compromise or fat emboli. This action aligns with the first step of the nursing process: Assessment and immediate Safety Intervention.

Distractor Analysis:
Watch out for confusion! While pain management (Option 1) is crucial for patient comfort and reducing anxiety, it is a supportive measure, not the immediate safety priority. Administering medication is important but comes after securing the injury.
Option 2, encouraging deep breathing exercises, is a valuable preoperative teaching and pulmonary hygiene intervention to prevent atelectasis and pneumonia. However, it is not the most urgent action when a limb is unstable.
Option 3, applying ice packs, is a correct non-pharmacological intervention for a fresh fracture to reduce swelling and provide some analgesia through vasoconstriction. Yet, like pain medication, it is secondary to the fundamental action of immobilization. You cannot effectively or safely apply ice if the limb is not properly stabilized first.

Related Concepts: This question integrates trauma nursing principles, preoperative care, and gerontological considerations. Elderly patients are at higher risk for complications from immobility and surgery, making proper initial management even more critical.
Concept Summary

Concept	Key Takeaway
Preoperative Priority for Fracture	Immobilize first. Prevent further injury (displacement, neurovascular damage) before addressing comfort or teaching.
Nursing Process in Trauma	Assessment/Safety (Immobilize) → Intervention (Pain meds, ice) → Teaching (Deep breathing, preoperative instructions).
Complications of Hip Fracture	Fat embolism, neurovascular compromise, hemorrhage, increased pain from movement.
Geriatric Considerations	Higher risk of delirium from pain, complications from immobility (pressure ulcers, pneumonia), and slower healing.

Side-by-Side Comparison!

Intervention	Priority Level & Rationale	When to Implement
Immobilization	HIGHEST PRIORITY. Foundational safety measure to stabilize the injury.	Immediately upon encounter, before any other specific care.
Pain Management	High Priority. Supports patient comfort and cooperation, reduces physiological stress.	As soon as possible, but after or concurrently with initial stabilization.
Preoperative Teaching (e.g., Deep Breathing)	Important but Lower Acuity. Prevents postoperative complications.	Once the patient is stable, comfortable, and able to participate in learning.

Anatomy, Physiology & Pharmacology Points The hip joint is a ball-and-socket joint. A fracture, often of the femoral neck, disrupts the blood supply to the femoral head, risking avascular necrosis. Movement can force fat globules from the bone marrow into the bloodstream, causing fat embolism syndrome (symptoms: hypoxemia, confusion, petechial rash). Immobilization minimizes this risk. Pain medications for such injuries are often opioids (e.g., morphine), requiring careful monitoring for respiratory depression, especially in the elderly.
Memory Tips Think "S.T.O.P. first" for acute musculoskeletal injury:
Stop movement (Immobilize).
Treat pain (Medicate).
Observe (Neurovascular checks).
Prepare (Preoperative teaching).
Also: "Fix the break before you take the ache."
High-Frequency NCLEX Topics Prioritization ("which action first?") is a classic NCLEX format. Trauma, postoperative care, and care of the elderly are heavily tested. The exam often presents a list of correct nursing actions, and you must choose the one that is most immediate or foundational.
Watch Out for Question Variations! * Instead of asking for the priority intervention, it might ask: "The nurse is preparing the client for surgery. Which finding requires immediate notification of the surgeon?" (Answer: Loss of pulse or sensation in the affected foot). * Or: "Which client statement indicates effective teaching regarding postoperative deep breathing exercises?" (Answer: "I will use the incentive spirometer 10 times every hour while I'm awake.").

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on the medical-surgical unit. An 82-year-old female, Mrs. Jones, is admitted from the ED after a fall at home. She has a confirmed left femoral neck fracture and is scheduled for an open reduction and internal fixation (ORIF) in the morning. She is alert but in significant pain, rating it 8/10.

Nursing Intervention Strategy: 1. Immediate Action & Assessment: Upon receiving the patient, first ensure the affected leg is immobilized. This is often done with a splint or by placing pillows longitudinally along the leg to prevent internal or external rotation. Then, perform a focused assessment: Pain (PQRST), neurovascular status of the affected limb (check pulses, capillary refill, sensation, movement, color, temperature - compare to unaffected side), vital signs, and skin integrity. 2. Pain Management: Administer prescribed analgesics (often IV opioids like morphine) promptly. Reassess pain after 30 minutes. Consider non-pharmacological methods like applying an ice pack (wrapped in a towel) to the hip area for 20-minute intervals, but only after the limb is stabilized. 3. Preoperative Preparation & Teaching: Once the patient is more comfortable, begin preoperative education. Explain deep breathing and coughing exercises using an incentive spirometer. Discuss the importance of early mobilization post-op (as ordered) to prevent complications. Complete preoperative checklists (NPO status, consent, lab work, skin prep). 4. Ongoing Monitoring & Safety: Perform neurovascular checks every 1-2 hours initially. Monitor for signs of complications: increased pain, pallor, pulselessness, paresthesia, paralysis (the 5 P's of compartment syndrome), or symptoms of fat embolism (sudden dyspnea, confusion, petechiae). Keep the side rails up and the call light within reach. Use a fracture bedpan.

Patient Safety and Precautions: * Key Point! Never attempt to "straighten" or significantly move a fractured limb. Immobilize it in the position found unless there is a loss of pulse. * Elderly patients are highly susceptible to delirium from pain, medications, and the unfamiliar environment. Reorient frequently, ensure adequate lighting, and involve family. * Be vigilant for signs of opioid-induced respiratory depression, especially in this age group.
Nursing Procedure & Medication Flow Immobilization Procedure: 1) Explain the procedure to the patient. 2) Gently support the limb above and below the fracture site. 3) Place pillows along the entire length of the leg to maintain neutral alignment. 4) Use a trochanter roll or abductor pillow if available to prevent external rotation. 5) Document the position and the patient's response.
Opioid Administration (e.g., Morphine): 1) Check the order and the "Rights" of medication administration. 2) Assess baseline pain level, respiratory rate, and oxygen saturation. 3) Administer IV push slowly. 4) Stay with the patient, monitor for adverse effects (respiratory rate < 12/min, sedation, hypotension). 5) Reassess pain in 30 minutes. Have naloxone (Narcan) readily available.
A Word from Your Senior Nurse "In the rush of an admission, it's easy to want to jump to the most visible need—like the patient's crying out in pain. But remember your trauma basics: first, do no further harm. Securing that fracture is the single most important thing you can do in those first minutes. It's the foundation upon which all other care—pain management, comfort, teaching—is built. On the NCLEX and at the bedside, thinking in terms of 'what protects the patient from immediate danger?' will almost always lead you to the right answer. You've got this!"