Practice Quiz

NCLEX-PN

Category - Safety

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A client becomes extremely agitated and aggressive. Physical restraints are placed to protect the client from injuring self and others. Which of the following actions is the nurse’s priority when monitoring the client?
  1. Assess for circulation in restrained extremities
  2. Assess the client’s urinary output every hour
  3. Assess for the client’s dietary needs
  4. Assess for the client’s level of consciousness
Explanation
Answer: A - The nurse’s priority when caring for a restrained client is to assess the circulation in restrained extremities. This action prevents skin breakdown and tissue damage. Chemical restraints were not utilized, so assessing the client’s level of consciousness is not a priority. The other options are also appropriate, but assessing the client’s restrained extremities is the most important action.
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