Practice Quiz

Certified Nursing Assistant Exam Prep

Category - Physical Care

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Ms. Walsh scratches and picks at a wound in her right foot. Because she is diabetic, the nurse obtained a doctor’s order to apply mitt restraints. You were delegated by the nurse to monitor Ms. Walsh after the restraints were applied. Which of the following are important to report to the nurse?
  1. Her heart rate
  2. Her respiratory rate
  3. The appearance of the wound
  4. If you feel a pulse in the restrained extremities
Explanation
Answer: D - Make sure the restraint is snug, not tight. Slide one or two fingers between the restraint and the wrist. Adjust the straps if the restraint is too loose or too tight. Check the client and the restraint every fifteen minutes; check for pulse, color, and temperature of the restrained part.
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