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NO.1 A violent client remains in restraints for several hours. Which of the following interventions is
most appropriate while he is in restraints?
A. Measure vital signs at least every 4 hours.
B. Release restraints every 2 hours for client to exercise.
C. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
D. Give fluids if the client requests them.
Answer: B

NCLEX-RN技術者   
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly
while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D)
Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle
tone, skin and joint integrity, and circulation.

NO.2 A 44-year-old female client is receiving external radiation to her scapula for metastasis of
breast cancer.
Teaching related to skin care for the client would include which of the following?
A. Teach her to cover broken skin in the treated area with a medicated ointment.
B. Encourage her to avoid direct sunlight on the area being treated.
C. Encourage her to wear a tight-fitting vest to support her scapula.
D. Teach her to completely clean the skin to remove all ointments and markings after each treatment
.
Answer: B

NCLEX-RN関連資料   NCLEX-RN専門知識   
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left
intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on
the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-
fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to
sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and
covering the area when she is in the sun.

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