A nurse is assessing a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

The client's hand is cool and pale.

The client has a capillary refill of 1 second.

The client has full range of motion in her wrist.

The client is attempting to remove the restraint.

Answer and Explanation

The Correct Answer is A

A. The client's hand is cool and pale: This indicates impaired circulation due to the restraint being too tight-a serious complication.
B. The client has a capillary refill of 1 second: This is a normal finding and indicates adequate perfusion.
C. The client has full range of motion in her wrist: This is a positive finding, not a complication.
D. The client is attempting to remove the restraint: This suggests agitation or discomfort but not necessarily a physical complication like impaired circulation.

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Correct Answer is D

Explanation

A. Walker: A walker is for clients who can bear some weight and participate in transfers, not for those requiring maximum assistance.
B. Draw sheet with two caregivers: This is more appropriate for repositioning in bed, not for safe transfer to a chair for a heavy client needing full assistance.
C. Sliding Board: A sliding board requires some upper body strength and minimal assistance-not suitable for maximum assist cases.
D. Mechanical Lift: A mechanical lift (e.g., Hoyer lift) is the safest option for transferring heavy clients who cannot assist themselves.

A. "I'll put a heating pad on my ankle at bedtime tonight." B. "I'll walk on my ankle for 10 minutes every hour." C. "I'll rewrap my ankle starting from the knee down." D. "I'll apply ice to my ankle for 20 minutes every hour."

Correct Answer is D

Explanation

A. "I'll put a heating pad on my ankle at bedtime tonight.": Heat is contraindicated in the first 24–48 hours of a sprain due to increased risk of swelling and bleeding.
B. "I'll walk on my ankle for 10 minutes every hour.": Weight-bearing should be minimized in the acute phase of a sprain.
C. "I'll rewrap my ankle starting from the knee down.": Wrapping should begin at the toes and go upward to promote venous return.
D. "I'll apply ice to my ankle for 20 minutes every hour.": Ice therapy helps reduce swelling and pain and should be applied 20 minutes at a time, typically every 1 to 2 hours during the first 24–48 hours.

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A nurse is assessing a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

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Naxlex Comprehensive Predictor Exams

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