Author Question: A client is becoming increasingly restless, and the nurse is concerned that the client may fall out ... (Read 101 times)

ap345 · **on:** Jul 22, 2018

A client is becoming increasingly restless, and the nurse is concerned that the client may fall out of bed. After obtaining a health care provider's order for a chest restraint, the nurse applies the restraint to the client.

What MUST the nurse document concerning this situation? a. client age, diagnosis, and time restraint is applied
b. generic name of restraint, where applied, and estimated time it will remain in place
c. reason for restraint, type of restraint used, time of placement, and condition of skin
d. name of prescribing health care provider, type of restraint, and time applied

Question 2

A client has a large abdominal dressing following abdominal surgery. Which of the following binders would be MOST appropriate for the nurse to apply?

a. Velcro c. double T
b. single T d. stretch net

sokh · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Documentation of restraints should include reason for restraint, type of restraint used, time of placement, and condition of skin. In addition, restraints will be released every 2 hours and the client assessed, toileted, and offered food or drink.

Answer to Question 2

A
Abdominal Velcro binders support the abdomen and hold abdominal dressings in place. Stretch net binders are not designed for support, but simply to hold the dressing in place.