When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

A) Remove the restraint.
B) Loosen the restraint.
C) Obtain a larger restraint.
D) Reapply the restraint with more padding.

Question

ramya sivanandam · Accepted Answer

Final Answer : A, Explanation :  If a patient has altered neurovascular status of an extremity,such as cyanosis,pallor and coldness of skin,or complaints of tingling,pain,or numbness,remove the restraint immediately,and notify the physician.Loosening the restraint may not effectively restore adequate circulation.An improperly sized restraint may not provide the protection needed for the patient.

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

A) Remove the restraint.
B) Loosen the restraint.
C) Obtain a larger restraint.
D) Reapply the restraint with more padding.

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Learning Objectives

Related questions

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?A) Remove the restraint.B) Loosen the restraint.C) Obtain a larger restraint.D) Reapply the restraint with more padding.

Definitions

Learning Objectives

Learning Objectives

Related questions

When assessing a patient,a nurse notes that the skin distal to a restraint is pale and cool to the touch.Which of the following interventions will the nurse perform first?

A) Remove the restraint.
B) Loosen the restraint.
C) Obtain a larger restraint.
D) Reapply the restraint with more padding.