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

Answer and Explanation

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.

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Correct Answer is D

Explanation

The rationale for this answer is that using distractions such as music, conversation, or toys can help reduce anxiety and agitation in clients with dementia who may resist bathing. It also helps create a positive and comfortable environment for the client.

A. Secure restraints to allow three fingers to slide under the restraints. B. Assess skin temperature and color before applying the restraints. C. Ensure that the client's bed is in the lowest position. D. Attach the client's restraints to the bed rail. E. Pad bony prominences before applying the restraints.

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

Explanation

The nurse should secure restraints to allow three fingers to slide under the restraints to prevent circulation impairment and nerve damage. The nurse should also assess skin temperature and color before applying the restraints to establish a baseline and monitor for signs of ischemia. The nurse should ensure that the client's bed is in the lowest position to reduce the risk of injury from falls. The nurse should pad bony prominences before applying the restraints to prevent skin breakdown and pressure ulcers. The nurse should not attach the client's restraints to the bed rail because this can cause injury if the bed is moved or adjusted. The nurse should attach the restraints to a part of the bed frame that moves with the client, such as the mattress support platform.

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A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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

Explanation

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