A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
Peripheral pulses
Comfort level
Skin integrity
Elimination needs
The Correct Answer is A
When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A decreased sense of balance is a normal age-related change that occurs in older adults due to changes in the vestibular system, vision, and proprioception. Nighttime urinary incontinence, increased nighttime sleeping, and heightened sense of pain are not normal findings and may indicate underlying health problems.
Correct Answer is D
Explanation
The nurse should include in report type of transmission-based precautions in place for client who has shingles, which is contact precautions. This information is essential for preventing spread of infection to other clients and staff members. The client's background health history, number of visitors during shift, and times for routine vital sign measurements are not specific or relevant information for this client's condition and do not need to be included in report.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today