When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client?
Select all that apply.
1. The client's range of motion
2. That the client's restraint is tied in a knot
3. The client's vital signs
4. The client's circulation
5. The client's hydration
Correct Answer: 1,3,4,5
When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
You might also like to view...
A patient who is receiving warfarin (Coumadin) has blood in his urinary catheter drainage bag. What medication will likely be ordered by the physician?
A) Aminocaproic acid (Amicar) B) Platelets C) Protamine sulfate D) Vitamin K
The nurse is assessing a client who has severe pre-eclampsia. The assessment finding that should be reported to the physician is:
1. 11 proteinuria. 2. Platelet count of 20,000. 3. Urine output of 50 ml per hour. 4. 21 DTRs.
In the results section of the research report, data that is aggregated means that:
A) the data is reported for the entire sample B) the data is raw data C) the data represents diversity in the sample D) the data is reported for each individual
A patient with atrial flutter is admitted to the unit and remains in atrial flutter for 24 hours. Which drug does the nurse anticipate will be given to attempt conversion to sinus rhythm?
a. Ibutilide (Covert) b. Warfarin (Coumadin) c. Verapamil (Calan) d. Diltiazem (Cardizem)