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
Recording output for a client who has multiple drains and tubes is a task that can be delegated to an AP, as it does not require nursing judgment or assessment skills. Reinserting an NG tube, teaching a family member how to change a dressing, and suctioning a tracheostomy are tasks that require nursing judgment, assessment skills, and specialized knowledge, and therefore cannot be delegated to an AP.
Correct Answer is C
Explanation
A total laryngectomy is a surgical procedure that removes the entire larynx (voice box) and separates the airway from the mouth, nose and esophagus. The client will have a permanent tracheostomy (an opening in the neck) and will not be able to speak normally. An artificial larynx is a device that produces sound by vibrating against the neck or cheek and allows the client to communicate orally. The nurse's priority intervention is to review the use of an artificial larynx with the client before surgery to facilitate postoperative communication and reduce anxiety.
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