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.

Clinical Context and Priority Setting

This scenario presents a classic NCLEX-RN priority question involving an elderly patient with a displaced femoral neck fracture awaiting hip replacement surgery. The patient reports severe pain rated 8/10 and requests to ambulate to the bathroom. The core of this question tests the nurse's ability to recognize that safety and prevention of further injury take precedence over patient autonomy in this specific clinical situation.

A displaced femoral neck fracture is inherently unstable. The fracture line disrupts the blood supply to the femoral head and creates a mechanical discontinuity between the femoral head and the femoral shaft. Any movement of the affected extremity—particularly weight-bearing or rotational movements such as those required to sit up, pivot, or use a bedside commode—can exacerbate the displacement, cause shearing forces at the fracture site, and increase the risk of damaging the retinacular vessels. This vascular compromise is a direct pathway to avascular necrosis of the femoral head, a devastating complication that can convert a treatable fracture into a lifelong disability. The literature underscores that these injuries represent a significant challenge and cause substantial disability in older adults, with high rates of morbidity even with appropriate surgical management ^[1][3].

Analysis of Incorrect Options

Option 1: Assist the patient to ambulate slowly to the bathroom with a walker.
Ambulation with a displaced femoral neck fracture is contraindicated. Weight-bearing on the affected limb generates compressive and rotational forces across the fracture site. This not only causes severe pain but also risks converting a closed, stable displacement into an open or more comminuted injury. The goal of preoperative management is strict immobilization to protect the remaining vasculature and maintain the alignment necessary for a successful total hip arthroplasty (THA) or hemiarthroplasty (HA) ^[1].

Option 2: Provide a bedpan and encourage the patient to void while lying flat.
While providing a bedpan addresses the elimination need without ambulation, the instruction to void while lying flat is not physiologically appropriate for most patients and can be extremely difficult, especially for an elderly patient in severe pain. Forcing a supine voiding position can lead to incomplete bladder emptying, urinary retention, and unnecessary discomfort. This option fails to incorporate a reasonable comfort measure that maintains spinal alignment while protecting the hip.

Option 3: Help the patient sit up on the bedside and use a bedside commode.
This option is the most dangerous because it appears to be a reasonable compromise but involves the high-risk movement of hip flexion and pivoting. Transferring from a bed to a bedside commode requires the patient to sit up, dangle the legs over the edge of the bed, and rotate the torso and pelvis to stand and pivot. These actions generate significant torque and angulation at the femoral neck fracture site. The mechanical stress can worsen displacement and cause intense pain. The narrative review on initial management strategies emphasizes that the primary focus before definitive surgical fixation is minimizing fracture site motion, a principle that directly contradicts any out-of-bed transfer ^[1].

Rationale for the Correct Answer: Option 4

Maintain strict bed rest and provide toileting assistance is the priority intervention because it aligns with the fundamental orthopedic principle of protecting an unstable fracture from further injury until surgical stabilization is achieved. "Strict bed rest" means the patient does not bear weight, flex the hip beyond a safe angle, or rotate the extremity. "Providing toileting assistance" means the nurse brings the toileting device to the patient in a manner that does not compromise fracture alignment. This involves using a fracture bedpan (which has a flatter, tapered edge designed to be slipped under a patient with minimal hip movement) and assisting the patient to a comfortable, semi-upright position if tolerated and not contraindicated, while maintaining the affected leg in neutral alignment with pillows or an abduction splint. The nurse must log-roll the patient or use a trapeze bar if available, ensuring the hip does not internally or externally rotate during bedpan placement.

This conservative approach is the standard of care preoperatively. The literature comparing surgical outcomes for femoral neck fractures consistently describes a preoperative phase focused on pain control, traction or immobilization, and prevention of secondary injury before proceeding to THA or HA ^[1]. A key goal of treatment, even postoperatively, is early mobilization, which is only possible because the fracture has been stabilized by the prosthesis ^[3]. To attempt mobilization before that stabilization is to invite the very complications—periprosthetic fracture, dislocation, and fixation failure—that the surgery is designed to prevent ^[3]. The nurse's priority is to maintain the integrity of the anatomical structures until the surgeon can perform the replacement, thereby optimizing the conditions for postoperative functional recovery as measured by tools like the Harris Hip Score .