When applying restraints on a client, the nurse would secure a ...

[stevenposner]

When applying restraints on a client, the nurse would secure a doctor's order and:
 
  1. Assess the restraints every 10 minutes.
  2. Pad bony prominences.
  3. Secure the restraint to the side rail.
  4. Tie the restraint with a square knot.

Question 2

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. The nurse advises the mother that she should:
 
  1. Omit the afternoon nap.
  2. Place a crib net over the top of the crib.
  3. Remove all objects from around the crib.
  4. Restrain the child if he gets up more than once.

[pikon]

Answer to Question 1

Correct Answer: 2
Rationale 1: The restraints should be assessed according to agency policy but no less frequent than every 2 hours.
Rationale 2: Padding bony prominences will prevent possible skin breakdown.
Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head.
Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled.

Answer to Question 2

Correct Answer: 2
Rationale 1: A child of 2 years should still be taking a nap, and that poses a dangerous situation, naptime or bedtime, if the child is still crawling out of the crib.
Rationale 2: A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib.
Rationale 3: Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib.
Rationale 4: Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib.

[stevenposner]

Both answers were spot on, thank you once again

[pikon]

Great! Please up vote