Evolve HESI Practice Exam

What should a nurse do first when observing blue fingers on a client wearing wrist restraints?

1. Notify the physician of the condition.

2. Loosen the right wrist restraint.

3. Check the circulation of the left hand.

4. Apply a warm compress to the affected hand.

The correct answer is: Loosen the right wrist restraint.

When a nurse observes blue fingers on a client wearing wrist restraints, the priority action is to ensure the circulation is adequate and that the restraint is not causing impairment. Loosening the right wrist restraint is the appropriate first step because it can immediately alleviate any pressure or restriction that might be causing compromised blood flow to the hand. Considering the condition indicated by the blue fingers, this could signify inadequate circulation, possibly due to tight restraints. By loosening the restraint, the nurse can help restore normal circulation and assess the situation further. Additionally, intervention to improve circulation should occur before notifying the physician or applying a warm compress, as those steps may not address the immediate problem of potential restraint-induced injury. Thus, addressing the cause of the altered color through loosening the restraint aligns with prioritizing patient safety and comfort, confirming that circulation is being effectively restored before proceeding with other interventions or notifications.