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.
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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Related Questions
Correct Answer is D
Explanation
The correct answer is d. Unplug the pump.
Rationale for Choice A:
- While notifying the biomedical department to fix the pump is important,it is not the immediate priority in this situation.The first step is to ensure patient and staff safety by removing the potential electrical hazard.
- Delaying the removal of the sparking pump could lead to electrical shock,fire,or other serious consequences.
- Biomedical staff can be notified after the immediate safety risk has been addressed.
Rationale for Choice B:
- Obtaining a replacement pump is necessary to continue the client's IV therapy,but it is not the first action the nurse should take.
- The priority is to eliminate the electrical hazard posed by the sparking pump.
- Once the faulty pump is unplugged and safety is ensured,the nurse can then proceed to obtain a replacement pump.
Rationale for Choice C:
- Labeling the pump with a defective equipment sticker is important to prevent others from using it,but it does not address the immediate safety risk.
- The priority is to disconnect the pump from the power source to eliminate the risk of electrical shock or fire.
- Labeling can be done after the pump has been unplugged and the situation has been assessed.
Rationale for Choice D:
- Unplugging the pump is the correct first action because it immediately removes the electrical hazard,preventing potential harm to the patient,staff,or equipment.
- This action prioritizes safety and mitigates the risk of electrical shock,burns,fire,or other serious consequences.
- It is essential to act quickly and decisively in such situations to ensure a safe environment for everyone involved.
Correct Answer is B
Explanation
A client with MRSA infection should be placed in a private room to prevent the spread of infection.
Choice A is wrong because an N95 respirator mask is not necessary when caring for a client with an MRSA infection.
Choice C is wrong because the proper sequence for removing personal protective equipment is to remove gloves first, then the gown.
Choice D is wrong because visitors do not need to wear a mask when they are within 3 feet of the client with an MRSA infection.
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