A health care provider orders that a confused and disoriented ...

[Destiiny22]

A health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges which of the follow-ing?
 
  a. Restraints are used on an as-needed basis.
  b. No orders or patient consents are needed.
  c. Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition.
  d. An order for restraints may be used inde-finitely until the patient no longer needs to be restrained.

Question 2

A patient has a peripheral IV. The nurse should assess the IV site for what primary signs and symptoms of infiltration? (Select all that apply.)
 
  a. Redness
  b. Swelling
  c. Pallor
  d. Warmth
  e. Red streaks

[perkiness]

Answer to Question 1

C
Restraints must be removed every 2 hours to allow for skin assessment, toileting, and nutrition. Restraints are only used when other less restrictive measures fail to prevent interruption of thera-pies. The physician's or health care provider's orders are necessary. The need for restraints must be reevaluated every 24 hours.

Answer to Question 2

B, C
An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein.

[Destiiny22]

TY

[perkiness]

You're welcome