The nursing assistant caring for a resident in wrist restraints observes the skin underneath the right restraint is pale, cool to touch, and the nail beds are blue. What action should the nursing assistant take first?

Question

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The nursing assistant observes that the circulation to the right hand and wrist is compromised because the skin is pale, cool to touch, and the nail beds are blue. The first action the nursing assistant should take is to loosen the restraint so two fingers may be easily slipped underneath and observe if the color of the skin and nails improves, compared to the left side. The assistant should then report the observations to the nurse and can go on to make sure the wrist restraints are secured correctly. If the restraint is properly applied the resident should be able to move fingers and hand through the range of motion while it is secured.

The Nursing Assistant Caring for a Resident in Wrist Restraints