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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is appropriate and necessary prior to the procedure. Bowel prep may include laxatives or enemas the evening before and possibly the morning of the procedure.
Correct Answer is B
Explanation
This is the nurse’s priority intervention for a client undergoing a total laryngectomy because it is important for the client to understand how to use an artificial larynx to communicate after the surgery.
Choice A is wrong because explaining the techniques of esophageal speech is not the priority intervention for a client undergoing a total laryngectomy.
Choice C is wrong because determining the client’s reading ability is not the priority intervention for a client undergoing a total laryngectomy.
Choice D is wrong because scheduling a support session for the client is not the priority intervention for a client undergoing a total laryngectomy.
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