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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Schedule the client as the first surgical procedure of the day.
When scheduling a surgical procedure for a patient with a latex allergy, it is recommended to schedule them as the first case of the day.
Choice A is wrong because removing the stopcocks from IV tubing does not address the issue of latex allergy.
Choice B is wrong because cleansing the stoppers with povidone-iodine before withdrawing medication does not address the issue of latex allergy.
Choice C is wrong because powdered gloves can contain latex and should be avoided for patients with a latex allergy.
Correct Answer is A
Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client’s prior coping mechanisms.
This can help the nurse understand how the client has dealt with difficult situations in the past and can provide insight into how the client may cope with their current diagnosis.
Choice B is wrong because while teaching the client to use progressive relaxation techniques may be helpful in managing stress and anxiety, it is not the priority intervention.
Choice C is wrong because while helping the client find a local support group may provide emotional support, it is not the priority intervention.
Choice D is wrong because while developing a list of goals with the client may provide direction and focus, it is not the priority intervention.
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