A nurse is assigned to care for a 45-year-old male who is admitted for alcohol withdrawal. On the second day of admission, the patient becomes disoriented and combative, and the provider places him in bilateral wrist restraints. Which physical exam finding is most important for this patient?

Distal capillary refill time. A patient in wrist restraints is at risk for impaired circulation in the distal upper extremities. Therefore, the most important physical exam finding to accurately assess and document is distal capillary refill time. Secondarily, a patient must be continually re-assessed for the need for restraints, however ensuring proper circulation is always the first priority. Brachial pulses are proximal to the wrist restraints so are less helpful in gauging adequate distal circulation. Although a patient in restraints may have limited mobility and be at a greater risk for skin breakdown over bony prominences, it is a less important assessment than distal circulation.

A nurse is assigned to care for a 45-year-old male who is admitte...

Category: Safety and Infection Control
Difficulty: 6

Topics: Cardiovascular Crisis Management Delegation, Prioritization and Leadership Health Care Ethics, Law, and Policy Health Care Quality Lifestyle Choices and High Risk Behavior Mental Health Disorders Tissue Integrity

Want help? View the answer with rationale.

Additional Safety and Infection Control Questions

Which action does the nurse take first when caring for a patient with meningococcal meningitis?

Question Type: Multiple Choice - Select One
Difficulty: 2

The nurse is assessing a neonate’s fit in the car seat for safety. The nurse notes the parent has placed the clip snugly against the infant’s chest at the level of the armpits; the nurse cannot pinch any slack at the shoulder straps. Which response by the nurse is appropriate?

Question Type: Multiple Choice - Select One
Difficulty: 5

The nurse is admitting a patient positive for human immunodeficiency virus (HIV). A fellow nurse states, “This patient is on contact precautions for his HIV status. You need to wear an isolation gown in addition to your gloves.” Which response by the nurse is most appropriate?

Question Type: Multiple Choice - Select One
Difficulty: 4

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Safety and Infection Control Questions

Nursing Careers

Nursing Degrees

NCLEX