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 {"dropdown-group-1":"D","dropdown-group-2":"D"}

Explanation

The rationale for identifying the client as at risk for hypoxia is based on the respiratory assessment findings. Diminished lung sounds in the posterior lobes suggest reduced air movement or potential complications such as atelectasis or pneumonia, which can impair gas exchange. Additionally, the decreased oxygen saturation of 84% on room air indicates inadequate oxygenation of the blood. Hypoxia occurs when there is insufficient oxygen supply to tissues, which can lead to serious complications if not addressed promptly. Therefore, recognizing these respiratory assessment findings is crucial for identifying the risk of hypoxia in the client.

A. Gloves B. Mask C. Gown D. Goggles

Correct Answer is A

Explanation

A. Gloves: When removing PPE for a client requiring airborne precautions, gloves should be removed first because they are considered the most contaminated item. Removing gloves first helps prevent contamination of other PPE and the healthcare provider's hands.

B. Mask: After removing gloves, the mask should be removed by grasping the ties or ear loops without touching the front of the mask. Removing the mask prevents the potential spread of infectious agents when the client is no longer in the immediate vicinity.

C. Gown: Following the removal of the mask, the gown should be removed, taking care to avoid touching the front of the gown. Removing the gown minimizes the risk of contamination to the healthcare provider's clothing or skin.

D. Goggles: If goggles were worn as part of the PPE for airborne precautions, they should be removed last after gloves, mask, and gown. Removing goggles last helps prevent any potential contamination of the eyes during the removal process.

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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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