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
The hand-off report is a verbal or written communication that provides essential information about the client's care, treatment, current condition and anticipated needs during a transition of care. The hand-off report should include information that is relevant, accurate, concise and timely. The effectiveness of the last dose of pain medication is an important information that should be included in the hand-off report, as it reflects the client's current pain level, response to treatment and need for further intervention.
Correct Answer is A
Explanation
The rationale for this answer is that a back massage is a non-pharmacological intervention that can help reduce pain by promoting relaxation and increasing blood circulation. It also shows respect for the client's preference and offers a choice of alternative therapy.
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