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.
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Related Questions
Correct Answer is C
Explanation
If a client expresses confusion or lack of understanding about a medical procedure, the nurse should notify the provider so that they can clarify any misunderstandings and ensure that the client is fully informed before giving their consent.
Choice A is wrong because providing brochures about the procedure may not be sufficient to address the client’s confusion or lack of understanding.
Choice B is wrong because completing an incident report is not an appropriate action in this situation.
Choice D is wrong because it is the provider’s responsibility to ensure that the client fully understands the procedure and gives informed consent.
Correct Answer is C
Explanation
The correct answer is choicec. “You will need to wear a mask when outside of your room.”
Choice A rationale:
Visitors wearing protective gowns is important to prevent infection, but it is not the primary teaching point for the patient themselves.
Choice B rationale:
Patients undergoing allogeneic stem cell transplants are typically placed in private rooms to minimize the risk of infection, not semi-private rooms.
Choice C rationale:
Wearing a mask when outside the room is crucial for the patient to protect themselves from infections due to their compromised immune system during the transplant process.
Choice D rationale:
Negative-airflow rooms are used to prevent the spread of airborne infections from the patient to others, not necessarily to keep the air cleaner for the patient.
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