A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
The client's hand is cool and pale
The client has full range of motion in her wrist
The client is attempting to remove the restraint.
The client has a capillary refill of less than 2 seconds.
The Correct Answer is A
A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 and a decrease in pH.
Analysis:
pH 7.22: Indicates acidemia (pH below 7.35), suggesting acidosis.
PaCO2 68 mm Hg: Elevated PaCO2 indicates hypoventilation, which is characteristic of respiratory acidosis.
Base excess -2: Base excess is within normal limits and does not contribute significantly to the acid-base imbalance in this scenario.
PaO2 78 mm Hg: PaO2 is slightly low but not significantly contributing to the acid-base imbalance.
Saturation 80%: Oxygen saturation is low, indicating hypoxemia, which is commonly associated with respiratory acidosis due to hypoventilation.
Bicarbonate 26 mEq/L: Bicarbonate is within normal limits, suggesting compensation for the respiratory acidosis, which is a chronic condition.
Overall, the ABG values indicate respiratory acidosis due to inadequate ventilation, leading to CO2 retention and subsequent acidemia.
Correct Answer is C
Explanation
A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.
B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.
C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.
D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.
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