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

Elimination needs

Comfort level

Skin integrity

Peripheral pulses.

Answer and Explanation

The Correct Answer is D

When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.

Choice A, Elimination needs, is important but not the first priority in this situation.

Choice B, Comfort level, is also important but not the first priority in this situation.

Choice C, Skin integrity, is important but not the first priority in this situation.

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Correct Answer is A

Explanation

After postoperative surgery, chances of infections are very high also discharges, color changes, etc.
So it is important to expose the client’s abdomen to look for changes in appearance.

Choice B is not the answer because determining areas of resonance across the abdomen using a systematic approach is not the first action that should be taken 1.
Choice C is not the answer because using the diaphragm of a stethoscope to listen for bowel sounds is not the first action that should be taken 1.
Choice D is not the answer because performing abdominal palpation by pressing gently with the finger pads is not the first action that should be taken 1.

A. The client's belief that his needs will be met through education. B. The nurse explains the need for education to the client. C. The client seeking family approval by agreeing to a teaching plan. D. The nurse's empathy about the client having to self-inject.

Correct Answer is A

Explanation

According to self-efficacy theory, learning develops from multiple sources, including perceptions of one’s past performance, vicarious experiences, performance feedback, affective/physiological states, and social influences.
Choice B is wrong because simply explaining the need for education to the client may not necessarily increase their motivation to learn.
Choice C is wrong because seeking family approval by agreeing to a teaching plan may not necessarily increase the client’s motivation to learn.
Choice D is wrong because the nurse’s empathy about the client having to self-inject may not necessarily increase their motivation to learn.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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