A 68-year-old patient with a displaced femoral neck fracture is scheduled for hip replacement surgery in 2 hours. The patient reports severe pain (8/10) and requests to get up to use the bathroom. What is the nurse's priority intervention?

For a displaced femoral neck fracture, strict bed rest is critical to prevent further displacement and complications like avascular necrosis. Other options involve movement that could worsen the fracture.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient with a displaced femoral neck fracture awaiting surgery. The core principle is preventing further injury and complications. A displaced fracture means the bone fragments are not aligned, and any movement can cause further displacement, damage surrounding blood vessels, or increase the risk of avascular necrosis (AVN) of the femoral head. The priority is to Key Point! immobilize the affected limb and maintain the patient on strict bed rest until definitive surgical stabilization is performed.

Answer Rationale: Option ④ is correct because it directly addresses the primary safety concern: preventing further harm. Key Point! "Maintain strict bed rest and provide toileting assistance" ensures the fractured hip is immobilized. The nurse should provide a bedpan or urinal and assist the patient with all activities of daily living (ADLs) to eliminate any weight-bearing or significant movement of the affected limb.

Distractor Analysis:
Watch out for confusion! Option ① (ambulate with a walker) is contraindicated. For a displaced fracture, the patient is typically non-weight-bearing (NWB) on the affected leg. Ambulation could cause severe pain, further displacement, and vascular injury.
Option ② (use bedpan while lying flat) is partially correct in using a bedpan but incorrect in encouraging voiding while lying flat. For many patients, especially older adults, voiding in a supine position is difficult and can lead to urinary retention. The nurse should assist the patient into a slight side-lying position (with proper support to the affected leg) to facilitate voiding, if possible, while still maintaining bed rest.
Option ③ (sit up and use commode) involves sitting up and transferring, which requires significant hip flexion and movement. This action could displace the fracture fragments and is not safe pre-operatively for a displaced fracture.

Related Concepts: The management of a hip fracture involves the RICE principle (Rest, Ice, Compression, Elevation) in the acute phase, with Rest being paramount. Pre-operative care focuses on pain management, prevention of complications (e.g., deep vein thrombosis (DVT), skin breakdown), and preparing the patient physically and psychologically for surgery. Post-operative care will then focus on early mobilization after the joint is surgically stabilized.
Concept Summary

Concept	Key Takeaway
Displaced Fracture	Bone fragments are out of alignment. Movement can worsen displacement and cause complications.
Pre-op Hip Fracture Care	Priority is immobilization (traction, strict bed rest) to prevent further injury until surgery.
Avascular Necrosis (AVN)	A major complication of femoral neck fractures due to disrupted blood supply to the femoral head.
Nursing Priority (Safety)	Always prioritize interventions that prevent harm. Do not move a fractured limb before stabilization.

Side-by-Side Comparison!

Scenario	Priority Intervention	Rationale
Displaced Femoral Neck Fracture (Pre-op)	Strict bed rest, immobilization, provide bedpan/urinal.	Prevent further displacement, vascular injury, and AVN.
Post-op Total Hip Replacement (Day 1)	Ambulate with physical therapy (PT), adhering to hip precautions (e.g., no flexion >90°).	Prevent DVT, pneumonia, and promote healing. The joint is now surgically stabilized.
Patient with Severe Pain & Urge to Void (General)	Address pain first (medicate), then assist with toileting.	Pain can inhibit voiding. However, in this fracture case, safety (immobilization) overrides the typical sequence.

Anatomy, Physiology & Pharmacology Points The femoral neck is a common fracture site in older adults, especially those with osteoporosis. Its blood supply is tenuous; the medial femoral circumflex artery is the primary source for the femoral head. A displaced fracture can tear this artery, leading to avascular necrosis. Pharmacologically, pain management is crucial. The nurse would anticipate administering IV opioids (e.g., morphine) pre-operatively, while monitoring for respiratory depression.
Memory Tips FRACTURE Priority Pre-Op: Fix the limb (immobilize), Restrict movement, Assess neurovascular status, Control pain, Toileting in bed, Urgent surgery prep, Risk reduction (DVT prophylaxis), Educate on bed rest.
Think: "Don't Move the Broken Bone!" Before surgery, the bone is unstable. After surgery, the new joint is stable, so you move.
High-Frequency NCLEX Topics This integrates prioritization (safety first), musculoskeletal nursing, and pre-operative care. NCLEX loves to test when to mobilize vs. when to immobilize. Remember: Key Point! For acute, unstable injuries (displaced fractures, spinal cord injury risk), immobilize. For post-op or chronic conditions (COPD, post-op), mobilize to prevent complications.
Watch Out for Question Variations! * Instead of toileting, the question could ask about pain management: "The patient reports severe pain. Which action should the nurse take first?" Answer: Medicate for pain as ordered (while maintaining bed rest). * The scenario could shift to post-operative day 1: "What is the priority intervention?" Answer would then focus on ambulation and DVT prevention. * It could test complication recognition: "Which finding requires immediate notification?" Answer: Signs of compartment syndrome (e.g., severe pain, pallor, paresthesia) or fat embolism syndrome (e.g., dyspnea, confusion, petechiae).

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on an orthopedic unit. Mr. Johnson, 68, fell at home and was diagnosed with a displaced left femoral neck fracture. He is scheduled for a total hip arthroplasty (THA) in 2 hours. He is anxious, rates his pain at 8/10, and insists he needs to get up to use the "real toilet."

Nursing Intervention Strategy: 1. Assessment: Perform a focused assessment. Check neurovascular status of the affected limb (CMS: Circulation, Movement, Sensation). Assess pain using a numeric scale. Assess bladder distension and last void. Evaluate skin integrity over bony prominences (sacrum, heels). 2. Communication & Education: Explain clearly and empathetically: "Mr. Johnson, I understand you're in pain and prefer the bathroom. However, moving your hip right now could seriously damage it before surgery. To keep you safe, I need you to stay in bed. I will help you use the bedpan, and I will give you medication for your pain right away." 3. Interventions: * Pain Management: Administer prescribed IV analgesic (e.g., morphine 2-4 mg) promptly. Reassess pain in 30 minutes. * Toileting: Provide a fracture bedpan (lower profile) or a urinal. Raise the head of the bed slightly if permitted (check if the patient is in traction) and provide privacy. Assist as needed. * Immobilization: Ensure the affected leg is supported with pillows or an abduction pillow to maintain neutral alignment. Do not rotate the leg internally or externally. * Pre-op Prep: Continue with standard pre-operative protocols (NPO status, skin prep, consent verification).

Patient Safety and Precautions: * Contraindication: Absolutely NO weight-bearing, sitting up, or dangling legs at the bedside before surgical fixation. * Medication Caution: Opioids can cause respiratory depression, hypotension, and constipation. Monitor vital signs closely, especially respirations. * Key Monitoring: Frequent neurovascular checks (every 1-2 hours), pain assessment, and monitoring for signs of complications like DVT (unilateral calf swelling, pain, redness) or fat embolism.
Nursing Procedure & Medication Flow Providing a Bedpan for a Patient with a Hip Fracture: 1. Explain the procedure. 2. Raise the head of the bed to a semi-Fowler's position if not contraindicated (e.g., by traction orders). 3. Have the patient flex the knee of the unaffected leg and press down with the foot. 4. Place one hand under the patient's sacrum and assist them to lift their hips. 5. Slide the bedpan into place with your other hand. For a fracture bedpan, the flat end goes under the buttocks. 6. After use, clean the patient, remove the bedpan, and return the bed to a flat position if needed for immobilization.
IV Opioid Administration (e.g., Morphine): * Dose: Typically 2-10 mg IV every 2-4 hours PRN. * Rate: Administer slowly over 4-5 minutes. * Monitoring: Have naloxone (Narcan) available. Monitor respiratory rate (< 12/min is a concern), oxygen saturation, blood pressure, and level of consciousness (LOC) before and after administration.
A Word from Your Senior Nurse "In orthopedics, your hands are your best assessment tool and your words are your most powerful intervention. A patient in severe pain and facing surgery is scared and wants control. Your job is to provide compassionate care while being the unwavering advocate for their safety. Explaining the 'why' behind strict bed rest—'to save the blood supply to your hip bone'—can turn frustration into cooperation. Always think: 'What is the greatest immediate threat to this patient?' For an unstable fracture, it's movement. Master this prioritization, and you'll excel not just on the NCLEX, but in every trauma and orthopedic shift you'll ever work."