A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
Peripheral pulses
Comfort level
Skin integrity
Elimination needs
The Correct Answer is A
When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should begin by testing the client while they are wearing glasses, as this reflects their usual visual acuity. The nurse should document the smallest line that the client can read on the chart, not the largest. The nurse should position the client 6m (20 feet) away from the chart, not 3.3m (10 feet). The nurse should instruct the client to begin the assessment with one eye covered and then switch to cover the other eye.
Correct Answer is D
Explanation
This intervention can help promote sleep by increasing serotonin levels in the brain, which have a calming effect. The other interventions are not appropriate for a client who has insomnia.
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