A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

The client's hand is cool and pale

The client has full range of motion in her wrist

The client is attempting to remove the restraint.

The client has a capillary refill of less than 2 seconds.

Answer and Explanation

The Correct Answer is A

A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.

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

Explanation

B. Post NO SMOKING signs in a prominent location in the home:
Oxygen supports combustion, making smoking or exposure to open flames highly dangerous in an oxygen-enriched environment. Posting NO SMOKING signs serves as a reminder to everyone in the household to avoid smoking or using open flames near the oxygen source.

C. Notify local fire department:
It's crucial to inform the local fire department that a client is using home oxygen therapy. This ensures that emergency responders are aware of the presence of oxygen in the home in case of a fire or emergency situation.

E. Check the tops of the ears for skin breakdown:
The nasal cannula can cause pressure on the tops of the ears, potentially leading to skin breakdown, especially with prolonged use. Checking for skin breakdown and providing appropriate skin care helps prevent complications and ensures the client's comfort.

A. Verify the oxygen flow rate every other day:
While it's essential to ensure that the oxygen equipment is functioning properly and that the prescribed flow rate is appropriate for the client's needs, checking it every other day may not be necessary unless there are specific concerns or changes in the client's condition.

D. Apply petroleum ointment to nares if they become dry and irritated:
While it's common for the nasal passages to become dry with oxygen therapy, applying petroleum ointment may not be recommended without consulting the healthcare provider first, as it can interfere with oxygen delivery and increase the risk of infection.

A. Severity B. Precipitating cause C. Region D. Quality

Correct Answer is A

Explanation

A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.

B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.

C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.

D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.

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A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

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