ATI RN
ATI Nurs 100 Fundamental Final Exam Questions
Extract:
Question 1 of 5
A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
Correct Answer: B
Rationale: The correct answer is B: The client’s hand is cold and pale. Loosening the restraint is necessary when there are signs of impaired circulation, such as coldness and pallor, to prevent tissue damage. If the hand is cold and pale, it indicates poor blood flow, which can lead to ischemia or tissue death. This is a critical finding that requires immediate action to prevent complications. The other choices are incorrect because: A: Attempting to remove the restraint may not necessarily indicate a need to loosen it. C: Having full range of motion in the wrist does not necessarily require loosening the restraint. D: Capillary refill less than 2 seconds is a normal finding and does not indicate a need to loosen the restraint.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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