Author Question: A physician orders restraints for a confused client who is at risk for injury by pulling out tubes ... (Read 107 times)

casperchen82 · **on:** Jul 23, 2018

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describes an accurate action to take when applying these restraints?

A) Apply restraints to the hands or wrists, never to the ankles.
B) Ensure that two fingers can be inserted between the restraint and the client's extremity.
C) Use a quick-release knot to tie the restraint to the side rail.
D) Remove the restraint at least every four hours, or according to agency policy.

Question 2

A doctor orders restraints for an older adult client who is disoriented from the pain medication she is taking. Which of the following is an appropriate guideline for applying these restraints?

A) Chemical restraints should be tried before using physical restraints.
B) The restraints can be ordered by the nursing supervisor in emergency situations.
C) The client's vital signs must be assessed every hour.
D) Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and children under 9 years within one hour.

tuwy · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: B
Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every two hours.

Answer to Question 2

Ans: D
Client with restraints must be monitored and reassessed as described in answer D. Restraints must be ordered by a physician, and client vital signs must be assessed every two hours.