The nurse is assessing a patient in ankle restraints and finds the extremities are cool and pale, nail beds are cyanotic, and capillary refill is >5 seconds. Which action should the nurse take first?
Place a blanket over the patient’s feet
Perform a complete head-to-toe assessment
Loosen the restraints
Assess the patient’s blood pressure and respiratory rate
The Correct Answer is C
Choice A reason: Placing a blanket over the feet may provide warmth but does not address the impaired circulation caused by tight restraints. Cool, pale extremities and delayed capillary refill indicate compromised blood flow, requiring immediate restraint adjustment, making this choice less urgent.
Choice B reason: A complete head-to-toe assessment is thorough but delays addressing the critical circulatory compromise indicated by cyanotic nail beds and prolonged capillary refill. Loosening restraints is the priority to restore blood flow, making this choice secondary.
Choice C reason: Loosening the restraints is the first action, as tight restraints likely cause impaired circulation, evidenced by cool, pale extremities, cyanosis, and capillary refill >5 seconds. Restoring blood flow prevents tissue damage, making this the priority intervention for patient safety.
Choice D reason: Assessing blood pressure and respiratory rate is important but not the first action. The localized circulatory issue from restraints requires immediate correction to prevent ischemia, making this choice less urgent than loosening the restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Keeping legs abducted with a pillow between them prevents dislocation of the hip prosthesis after total hip replacement. This maintains joint stability by avoiding adduction and internal rotation, which can dislodge the implant, making it the correct intervention.
Choice B reason: Flexing the knee on the affected side risks hip dislocation, as excessive flexion (beyond 90°) strains the prosthesis. Abduction with a pillow is the standard to maintain alignment, making this an incorrect and unsafe action.
Choice C reason: Turning the patient to the affected side is not recommended, as it may cause the hip to adduct or rotate, risking dislocation. Abduction with a pillow ensures safe positioning, making this an incorrect intervention for hip replacement care.
Choice D reason: Changing the patient’s position is vague and does not specify safe technique. Specific positioning, like leg abduction with a pillow, is critical to prevent complications, making this choice too general and less appropriate than the targeted intervention.
Correct Answer is B
Explanation
Choice A reason: Canned soup is high in sodium due to preservatives, unsuitable for a low-sodium diet. Fresh, unprocessed foods are preferred, making this an incorrect recommendation for the client.
Choice B reason: Fresh apples are naturally low in sodium and align with a low-sodium diet. They provide nutrition without added salt, making them the correct food to recommend.
Choice C reason: Processed cheese contains high sodium levels for flavor and preservation, inappropriate for a low-sodium diet. Low-sodium alternatives are needed, making this incorrect.
Choice D reason: Pickles are high in sodium due to brining, contraindicated for a low-sodium diet. Fresh fruits like apples are better choices, making pickles an incorrect recommendation.
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