Author Question: A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue ... (Read 42 times)

melly21297 · **on:** Jul 22, 2018

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next?

a. Remove the restraint.
b. Place a blanket over the feet.
c. Immediately do a complete head-to-toe neurologic assessment.
d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

Question 2

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?

a. Pathogenic asepsis
b. Medical asepsis
c. Surgical asepsis
d. Clean asepsis

leahm14 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

Answer to Question 2

ANS: C
The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.