Practice Question
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?
Answer Choices:
Correct Answer:
Peripheral pulses
Rationale:
🔶 When a client has restraints, circulatory compromise is the highest priority, making peripheral pulse assessment the first nursing action.
🔶 Early detection of impaired circulation helps prevent nerve damage, skin breakdown, or even tissue necrosis.
🔶 Restraints can reduce blood flow, especially if not applied correctly or monitored regularly.
🔶 This assessment is part of ensuring safe use of restraints according to patient safety protocols.
🔶 Frequent monitoring ensures adequate perfusion and tissue integrity are maintained.
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This question is from RN ATI Nursing Care of Children~ 2020 which contains 57 questions.
More Questions from This Exam
A nurse is assessing an older adult client. Which of the following findings should the nurse expect?
Answer Choices:
A. Decreased sense of balance
B. Nighttime urinary incontinence
C. Increased nighttime sleeping
D. Heightened sense of pain
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?
Answer Choices:
A. Evaluate the client's response to pain medication.
B. Monitor the characteristics of the client’s chest tube drainage.
C. Teach deep breathing and coughing to the client.
D. Assist the client to select food choices from the menu.
A nurse is providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?
Answer Choices:
A. Explain the need to have another adult drive the client home following surgery.
B. Ask the client to shower 3 times the day before surgery.
C. Inform the client that they can wear makeup during surgery.
D. Instruct the client to stop drinking clear liquids 1 hr before surgery.
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
Answer Choices:
A. This test will determine if your heart is performing properly.
B. This test will indicate if you are at risk for developing blood clots.
C. This test will provide information about the function of your liver.
D. This test is used to check how your kidneys are working.
A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?
Answer Choices:
A. Ask a family member of the client to translate for the nurse.
B. Speak to the client while indicating printed instructions in the client’s language.
C. Arrange for a video conference with an interpreter who speaks the client’s language.
D. Find an assistive personnel who speaks the client's language.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 4