Question

A nurse is assessing a client who has wrist restrain applied. For which of the following findings should the nurse loosen the restrain?

a.client has capillary refill of less than 2 seconds
b.client has full range of motion in her wrist
c. the client is attempting to remove the restraint
d.client's hand is cool and pale

Answer 1

The nurse should loosen the restrain if the client has capillary refill of less than 2 seconds. Full range of motion, attempting to remove the restraint, or a cool and pale hand are not indications for loosening the restraint.

Step-by-step explanation:

The nurse should loosen the wrist restraint if the client has capillary refill of less than 2 seconds. Capillary refill is a test used to assess circulation and adequate blood flow to the extremities. A refill time of less than 2 seconds indicates normal blood flow, while a longer refill time may suggest poor circulation. Loosening the restraint in this case can help improve blood flow and prevent complications.

The other findings mentioned, such as the client having full range of motion in her wrist, attempting to remove the restraint, or having a cool and pale hand, are not indications for loosening the restraint. Full range of motion in the wrist suggests that the client has good mobility, attempting to remove the restraint may indicate resistance or agitation, and a cool and pale hand may indicate reduced blood flow. These findings do not necessarily require loosening the restraint, but they should be assessed by the nurse for further intervention if necessary.