The female client wearing bilateral wrist restraints complains that her hands are numb and the nurse assesses pale, cool fingers. Which is the nurse's priority intervention?
1. Notify the provider quickly.
2. Remove the wrist restraints.
3. Try another type of restraint.
4. Increase the restraint padding.
2
2. The client displays clinical indicators of neurovascular impairment and a delay in resolving the problem can result in tissue damage, so the nurse removes the restraint, thoroughly assesses the extremities, and plans nursing care.
1. The nurse notifies the provider after assessing the client.
3. Before another type of restraint is applied, the nurse completes the assessment and notifies the provider as necessary. A physical restraint is contraindicated if the client has impaired perfusion or tissue damage in an area restricted by the restraint.
4. Increasing the padding is a reasonable intervention after the nurse's assessment and provider notification.
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