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Read the following case study, then refer to it to answer the questions.

The nurse is caring for a 22-year-old male client admitted with multiple injuries resulting from a motor vehicle accident.

Primary Care Provider: Nurse's Notes

Admitting Notes:

- 1955: Alert and oriented 22-year-old client admitted post motor vehicle accident (rear-ended) after being seen in ED.
- Diagnosis: Fracture of right femur, right clavicle, and right ribs 5 & 6. Seat belt contusion noted across chest. Chest wall symmetrical. No lifts, heaves, or thrills. No murmurs, gallops, or rubs are auscultated. S1 and S2 are of normal intensity. No S3, S4. EKG shows sinus tachycardia at [tex]$114 / \text{min}$[/tex]. Pulse oximetry reading [tex]$98\%$[/tex] on oxygen [tex]$2 L / \text{nc}$[/tex]. Lungs clear bilaterally. Radial pulses equal [tex]+3 /+4[/tex] and regular. Pedal pulses: Right [tex]+2 /+4[/tex], Left [tex]+3 /+4[/tex]. Pain of 9 on a 1-10 pain scale to right shoulder, right chest, and right leg relieved with morphine 4 mg IV.
- Vital signs: T [tex]98.2^{\circ} F \left(36.7^{\circ} C \right)[/tex], RR 24 shallow, BP 148/88. Skin warm and dry. Right arm immobilized in sling. Scheduled for open reduction and internal fixation (ORIF) right femur.

- 2230: Client stable following ORIF right femur. Alert, oriented. Vital signs within normal limits/afebrile. Lactated Ringers 1 liter infused. Post-op Hct: 36. Fiber cast dry/intact. Post-op plan: IV hydration, Cefoxitin 1 gram every 8 hours, physical therapy.

Question:

Drag the potential interventions the nurse should take to care for this client to the box on the right. Choose only the steps that are appropriate.

Potential Interventions:
- Place client in left lateral position.
- Request a stat chest X-ray.
- Perform chest physiotherapy.
- Initiate oxygen at [tex][tex]$2 L /$[/tex][/tex] nasal cannula.
- Place thoracotomy tray at bedside.
- Have client perform incentive spirometry hourly.

Appropriate Interventions:



Answer :

GinnyAnswer
To determine the appropriate interventions for the nurse to take care of the client described in the case study, let's analyze the relevant information provided:

1. Client condition:
- The client is a 22-year-old male with multiple injuries from a motor vehicle accident.
- Fractures: right femur, right clavicle, and right ribs 5 & 6.
- Seat belt contusion across the chest.
- Chest wall is symmetrical, lungs clear bilaterally, and no abnormal heart sounds.
- Pulse oximetry reading is 98% on oxygen at 2 L/nasal cannula.
- Postoperative status after an open reduction and internal fixation (ORIF) of the right femur.
- Pain rated 9/10, relieved with morphine.
- Post-operative hematocrit is 36.

2. Analyzing Vital Sign and Physical Exam Findings:
- Vital Signs: T: 98.2°F (36.7°C), RR 24 (shallow), BP 148/88, Pulse: 114 bpm (sinus tachycardia).
- Radial and pedal pulses are strong and regular.
- Postoperative plan includes IV hydration, antibiotics (Cefoxitin), and physical therapy.

3. Identifying Potential Interventions:
- The client already has oxygen initiated at 2 L/nasal cannula as evident from the case study. Given their current respiratory status with clear lungs and a pulse oximetry reading of 98%, maintaining this intervention is appropriate.
- Incentive spirometry is important for encouraging deep breathing which helps prevent atelectasis (collapsed lung) and promotes optimal lung expansion, especially after surgery and with rib fractures.

Appropriate Interventions:

- Initiate oxygen at 2 L/nasal cannula:
- This intervention ensures that the client is receiving a continuous supply of oxygen, which is essential given the rib fractures and postoperative state.

- Have client perform incentive spirometry hourly:
- This intervention helps to improve lung function by encouraging deep breaths, which is crucial for preventing postoperative complications such as pneumonia or atelectasis, especially considering the rib fractures.

Based on the client's condition and the medical history provided, these are the most appropriate interventions to ensure the client's respiratory status remains stable and to promote recovery:

- Initiate oxygen at 2 L/nasal cannula
- Have client perform incentive spirometry hourly

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