Author Question: When putting a client in restraints, the nurse will need to assess the client per policy. Which ... (Read 41 times)

james9437 · **on:** Jun 25, 2018

When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client?

Select all that apply.
1. The client's range of motion
2. That the client's restraint is tied in a knot
3. The client's vital signs
4. The client's circulation
5. The client's hydration

Question 2

The nurse is delegating supportive care to the unlicensed assistive personnel (UAP) for several clients on a medical-surgical unit. Which statement made by the UAP warrants the need for more information?

1. I can untie the restraint when giving the client a bath.
2. I will make sure to tie the restraint in a slip-knot.
3. I will inform you of any changes to the skin.
4. I will assist the client with hygiene.

meltdown117 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1,3,4,5

When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.

Answer to Question 2

Correct Answer: 1

The UAP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions to the UAP. All the other statements indicate an appropriate understanding by the UAP.