A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?

Elimination needs

Comfort level

Skin integrity

Peripheral pulses.

Answer and Explanation

The Correct Answer is D

When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.

Choice A, Elimination needs, is important but not the first priority in this situation.

Choice B, Comfort level, is also important but not the first priority in this situation.

Choice C, Skin integrity, is important but not the first priority in this situation.

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Correct Answer is ["B","D","E"]

Explanation

The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.

The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.

The heart rate has increased from 66/min to 104/min.

The level of consciousness is always an important factor to monitor in a patient.

A. Temperature: The temperature has only changed slightly and is within the normal range.

C. Respiratory rate: The respiratory rate has increased but is still within normal range.

G. Skin color and temperature: This information is not provided in the exhibit.

A. "Your visitors will need to wear protective gowns." B. "You will be placed in a semi-private room." C. "You will need to wear a mask when outside of your room." D. "You will be in a negative-airflow room to keep the air cleaner.".

Correct Answer is C

Explanation

The correct answer is choicec. “You will need to wear a mask when outside of your room.”

Choice A rationale:

Visitors wearing protective gowns is important to prevent infection, but it is not the primary teaching point for the patient themselves.

Choice B rationale:

Patients undergoing allogeneic stem cell transplants are typically placed in private rooms to minimize the risk of infection, not semi-private rooms.

Choice C rationale:

Wearing a mask when outside the room is crucial for the patient to protect themselves from infections due to their compromised immune system during the transplant process.

Choice D rationale:

Negative-airflow rooms are used to prevent the spread of airborne infections from the patient to others, not necessarily to keep the air cleaner for the patient.

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A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?

Correct Answer is C

Explanation

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