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
In general, parental (or legal guardian) consent is required for any diagnostic or surgical procedure performed on a child under the age of 181.
Choice A is wrong because the mother’s 21-year-old sibling is not a parent or legal guardian of the infant.
Choice B is wrong because the infant’s provider cannot sign the consent form on behalf of the infant.
Choice C is wrong because the infant’s grandparent cannot sign the consent form unless they are a legal guardian of the infant.
Correct Answer is C
Explanation
The Weber test is a screening test for hearing performed with a tuning fork that can detect unilateral conductive hearing loss and unilateral sensorineural hearing loss.
To perform Weber’s test, strike the fork against your knee or elbow, then place the base of the fork in the midline, high on the patient’s forehead.
Choice A is wrong because delivering a series of high-pitched sounds at random intervals is not part of Weber’s test.
Choice B is wrong because holding an activated tuning fork against the client’s mastoid process is part of Rinne’s test, not Weber’s test.
Choice D is wrong because whispering a series of words softly into one ear is not part of Weber’s test.
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