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 C
Explanation
The name of the client's next of kin. The rationale for this answer is that the name of the client's next of kin is a unique identifier that can be verified by the client or by checking the medical record.
Correct Answer is C,A,B,D
Explanation
The correct sequence of steps for palpating a client's systolic blood pressure using brachial artery is as follows:
- Palpate brachial pulse site.
- Inflate blood pressure cuff to 30 mm Hg beyond where brachial pulse was last felt. - Deflate blood pressure cuff slowly until brachial pulse is detected.
- Discontinue palpation of brachial pulse.
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