Editing Fundamentals of Nursing – LPN Practice Questions (section)

==Question 15==
The licensed practical nurse notes that a patient in soft wrist restraints has cool, dusky fingers with delayed capillary refill on the right hand. What should the nurse do first?
# Document the finding and recheck in one hour.
# Loosen or release the right restraint, assess circulation and skin, and notify the registered nurse.
# Tighten the left restraint to keep the limbs symmetrical.
# Remove both restraints permanently without notifying anyone.

'''Answer:''' 2. Loosen or release the right restraint, assess circulation and skin, and notify the registered nurse.

''Rationale:'' Cool, dusky fingers with delayed capillary refill indicate impaired circulation from a restraint that is too tight, which can cause nerve and tissue injury. The nurse relieves the compression immediately, assesses circulation, sensation, motion, and skin, and reports to the registered nurse. Restrained patients require circulation checks every 15 to 30 minutes per policy and release for range of motion, repositioning, toileting, and fluids at least every 2 hours. Option 1 delays care during active tissue compromise. Option 3 is not a legitimate intervention and worsens the risk. Option 4 removes a prescribed safety measure without assessment or communication, which is unsafe and outside independent decision making.

[[Category:Fundamentals of Nursing]]
[[Category:Licensed Practical Nurse (NCLEX-PN)]]
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