A 45-year-old client with a history of osteoporosis is admitted to the emergency department after falling at home and sustaining a displaced femoral neck fracture. The client is scheduled for surgical repair. Which nursing intervention should be the priority during the preoperative period?

Maintaining proper alignment and immobilization is key to prevent further displacement and complications before surgery. Other options could worsen the fracture or are not priorities.

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient with a displaced femoral neck fracture in the preoperative period. The core principle is preventing further injury and managing pain before definitive surgical repair. A displaced fracture means the bone ends are not aligned, which can damage surrounding nerves, blood vessels, and soft tissue. The priority is to stabilize the injury to prevent complications like increased bleeding, nerve damage, or conversion to an open fracture.

Answer Rationale: Key Point! The correct answer is Maintain the affected leg in proper alignment and immobilization. This is the highest priority because it directly addresses patient safety by preventing further displacement of the fracture fragments. Proper alignment minimizes pain, reduces the risk of neurovascular compromise, and prevents additional soft tissue injury. Immobilization is a standard preoperative measure for any unstable fracture.

Distractor Analysis:

1. Watch out for confusion! Encourage early ambulation: This is contraindicated for an unstable, displaced fracture. Ambulation without surgical fixation would cause severe pain, further displacement, and potential catastrophic injury. Early ambulation is a postoperative goal after stabilization.
2. Apply ice packs to the fracture site every 2 hours: While applying ice (cryotherapy) can help reduce swelling and pain, it is a supportive measure, not the priority intervention. The primary threat to the patient is movement causing further injury, which immobilization addresses first.
3. Perform passive range of motion exercises: This is inappropriate for an acute, displaced fracture. Any movement of the joint near the fracture site can displace the fragments further. ROM exercises are part of rehabilitation after the fracture has been surgically stabilized.

Related Concepts: This question integrates knowledge of musculoskeletal trauma, the nursing process (prioritization using Maslow's hierarchy or ABCs—circulation to the limb is a key concern), and preoperative care. The underlying osteoporosis history is a risk factor for the fracture but does not change the acute management priority.

Concept Summary

Concept	Key Takeaway
Preoperative Fracture Care	Priority is immobilization and alignment to prevent further injury.
Displaced Fracture	Bone ends are out of position. Requires stabilization before any movement.
Nursing Prioritization	Safety (preventing harm) takes precedence over comfort measures (ice) or future rehab (exercises).
Femoral Neck Fracture	High risk for avascular necrosis (AVN). Careful handling is crucial to preserve blood supply.

Side-by-Side Comparison!

Intervention	Preoperative Phase (Acute, Unstable)	Postoperative Phase (Stabilized)
Mobility	Strict immobilization (e.g., traction, splint). No weight-bearing.	Early, controlled ambulation as per protocol to prevent DVT, pneumonia.
Pain Management	Immobilization is primary. Add analgesics and ice.	Analgesics, then transition to activity-related pain management.
Exercises	Contraindicated at fracture site.	Prescribed ROM and strengthening exercises begin.

Anatomy, Physiology & Pharmacology Points

• Anatomy: The femoral neck is a common fracture site in osteoporosis. Its blood supply is tenuous, making it prone to avascular necrosis (AVN) if disrupted.
• Pathophysiology: Displacement shears blood vessels and nerves. Immobilization minimizes this shearing force.
• Pharmacology (Implied): Preoperative pain management often includes opioids (e.g., morphine) and NSAIDs. Remember to assess neurovascular status before and after analgesic administration.

Memory Tips

• RICE + Priority: For musculoskeletal injuries, remember Rest, Ice, Compression, Elevation. But in nursing prioritization for an unstable fracture, Rest (Immobilization) comes first and foremost before I, C, or E.
• ABCs for Limbs: Just like Airway, Breathing, Circulation for the body, think of Alignment, Bleeding, Circulation for a fractured limb. Alignment is the first step to protect circulation.

High-Frequency NCLEX Topics The NCLEX loves testing priority-setting in acute injury scenarios. A displaced fracture is an acute, unstable situation. Always choose the intervention that prevents further harm or addresses the greatest threat to physiological integrity first. Immobilization is a classic, high-yield answer for any acute fracture care question.

Watch Out for Question Variations!

• Instead of asking for the priority intervention, the question might ask: "The nurse should question which physician order?" The answer would be an order for "ambulate with assistance" or "perform ROM exercises" preoperatively.
• The scenario could shift to a postoperative patient, where the priority becomes preventing complications like deep vein thrombosis (DVT) or pneumonia through early ambulation and incentive spirometry.
• It could combine with neurovascular assessment: "Which finding requires immediate intervention?" Answer: Absent pedal pulse or new numbness (signs of compromised circulation).

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the ED. Mr. Jones, 45, is on a stretcher after a fall. His right leg is noticeably shortened and externally rotated—a classic sign of a femoral neck fracture. He is in significant pain and anxious about surgery.

Nursing Intervention Strategy:

1. Immediate Assessment & Immobilization:
   • Assessment: Perform a focused neurovascular assessment (6 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia/coolness) on the affected limb. Assess pain level using a scale. Check skin for integrity.
   • Intervention: Collaborate with the team to apply skeletal traction or ensure the limb is supported in a position of comfort with pillows or a splint to maintain alignment. Do not attempt to "straighten" the limb.
2. Pain Management: Administer prescribed IV analgesics (e.g., morphine). Reassess pain after administration. Remember, effective immobilization is itself a powerful pain intervention.
3. Monitoring & Preparation:
   • Monitor vital signs for signs of bleeding or shock (tachycardia, hypotension).
   • Apply ice packs (wrapped in a towel) to the hip area to reduce swelling, but ensure it does not compromise the immobilization.
   • Complete preoperative checks (NPO status, consent, labs, allergies).

Patient Safety and Precautions:

• Contraindication: Never put weight on or actively move a displaced fracture. Log-roll the patient carefully for any necessary care.
• Medication Caution: Opioids can cause respiratory depression and hypotension. Monitor SpO2 and respiratory rate closely, especially in an older adult or if other injuries are suspected.
• Key Monitoring: Serial neurovascular checks are mandatory. Any deterioration (increased pain, loss of pulse, new numbness) is a surgical emergency and must be reported immediately.

Nursing Procedure & Medication Flow Procedure: Maintaining Limb Alignment with Pillows 1. Use several pillows or a specialized abduction pillow. 2. Support the entire length of the leg, from the heel to above the fracture site. 3. Ensure the hip is in a neutral position, preventing external or internal rotation. 4. Secure the pillows with tape or a sheet to prevent slipping, but avoid tight wrapping. 5. Re-check alignment and neurovascular status after positioning.

Medication: IV Morphine Administration - Action: Opioid agonist for severe pain. - Precautions: Administer slowly. Have naloxone (Narcan) and resuscitation equipment available. Assess pain and sedation level before and after (15-30 min). - Patient Education: "This medication will help with the sharp pain. It might make you feel sleepy. Please use your call bell if you need to move or feel short of breath."

A Word from Your Senior Nurse "In the rush of the ED, it's easy to focus on the monitors and the meds. But for this patient, your most important nursing action might be the simple, careful act of propping that leg just right with pillows and checking those toes every hour. That vigilance protects the limb's future function. On the NCLEX and in practice, never underestimate the power of a fundamental, safety-first intervention. It's often the difference between a good outcome and a preventable complication."