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 D
Explanation
Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. Health promotion guidelines are recommendations that help people prevent diseases and maintain optimal health status. One of the guidelines that the nurse should include in the teaching for young adult male clients is to have a dental examination every 6 months, as this can help prevent oral diseases and detect any problems early.
Correct Answer is ["A","B","E"]
Explanation
The nurse should secure restraints to allow three fingers to slide under the restraints to prevent circulation impairment and nerve damage. The nurse should also assess skin temperature and color before applying the restraints to establish a baseline and monitor for signs of ischemia. The nurse should ensure that the client's bed is in the lowest position to reduce the risk of injury from falls. The nurse should pad bony prominences before applying the restraints to prevent skin breakdown and pressure ulcers. The nurse should not attach the client's restraints to the bed rail because this can cause injury if the bed is moved or adjusted. The nurse should attach the restraints to a part of the bed frame that moves with the client, such as the mattress support platform.
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