The nurse is applying restraints to a client. After securing a ...

[clmills979]

The nurse is applying restraints to a client. After securing a health care provider's order, what should the nurse do?
 
  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 nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client?
 
  1. Client wanders around the care area.
  2. Client is picking at the access site for intravenous infusion of chemotherapy.
  3. Client needed to use the bathroom and waited for help but didn't want to soil the bed and fell while attempting to walk to the bathroom.
  4. Client does not want to stay in bed but wants to sit in the lounge with others.

[covalentbond]

Answer to Question 1

Correct Answer: 2
Rationale 1: The restraints should be assessed according to agency policy but no less frequently 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: Restraints cannot be used for the convenience of the care staff.
Rationale 2: In this situation, the client's actions could hinder his or her health status and a restraint would be indicated.
Rationale 3: This situation would not call for the client to be restrained. The care staff needs to be more attentive to the client's needs.
Rationale 4: This client would not be a candidate for restraints.

[clmills979]

Thanks for the timely response, appreciate it

[shailee]

Excellent