The nurse completes yearly training regarding the use of ...

[cnetterville]

The nurse completes yearly training regarding the use of restraints. Which situation would the nurse categorize as a restraint?
 
  1. A safety belt applied across the client's waist when sitting in a geri chair with a quick release button demonstrated to the client
  2. The use of the top side rail to provide something for the client to hold on to when getting out of bed
  3. A safety belt around the infant when placing the child in a swing
  4. The use of all four side rails on the bed after administering preoperative sedation

Question 2

The nurse is caring for a young pediatric client who is focused on pulling out the IV line in the right arm. Which type of restraint is the most appropriate for this client?
 
  1. Elbow restraint to the right arm
  2. Elbow restraint to the left arm
  3. Mitt restraint to the right hand
  4. Wrist restraint to the left arm

[mcomstock09]

Answer to Question 1

Correct Answer: 4

When the nurse pulls all four side rails up on the client's bed, he is restraining the client unless he obtains the client's permission prior to administering the preoperative sedation. The safety belt applied to the adult is not a restraint, because the client is shown how to open the belt if she wishes to remove it. A safety belt applied to an infant seat is not a restraint; it does not limit the child's movement, because the infant could not voluntarily get out of the chair without injury. Raising one side rail for support is not restraining the client because she can still get out of bed.

Answer to Question 2

Correct Answer: 2

The nurse would apply an elbow restraint to the arm that does not have the IV, because the client would reach with the left arm. Restraining the right arm or hand with the IV line would not limit the left hand from pulling the IV. Wrist restraints would limit all movement of the arm, whereas elbow restraints would only limit bending of the elbow, so this is the less restrictive and best choice.

[cnetterville]

Thank you

[mcomstock09]

No problemo