When assessing a client, a nurse notes that the skin distal to a ...

[mrsjacobs44]

When assessing a client, a nurse notes that the skin distal to a restraint is pale and cool to the touch. The nurse should:
 
  A. Remove the restraint
  B. Loosen the restraint
  C. Obtain a larger-size restraint
  D. Reapply the restraint with more padding

Question 2

MC When a client is in shock, the most important nursing observation is a (an) 1) Increase in pulse rate 2) Decrease in respirations 3) Increase in blood pressure 4) Decrease in blood pressure Which phase of the nursing process is illustrated
 
  in this question? A. Assessment
  B. Planning
  C. Implementation
  D. Evaluation

[xMRAZ]

Answer to Question 1

A
A. Client has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or complaints of tingling, pain, or numbness. Remove restraint immediately, and notify physician.
B. Loosening the restraint may not adequately restore adequate circulation.
C. A improperly sized restraint may not provide the protection for the client that is needed.
D. Pale and cool skin distal to the restraint requires additional assessment, and the restraint needs to be removed.

Answer to Question 2

A

[mrsjacobs44]

TYSM

[chereeb]

Gracias!