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Difficulty: HardUse of Restraints and Safety Devices

A practical nurse (PN) is caring for a client with acute encephalitis who is severely confused and repeatedly attempts to remove an intravenous (IV) catheter. After alternative measures have failed to keep the client safe, the healthcare provider prescribes bilateral soft wrist restraints.

Which of the following actions should the PN take while the client is restrained? (Select all that apply)

  1. Remove the restraints at least every 2 hours to assess the skin and perform range-of-motion exercises.Answer
  2. Attach the restraint straps to a part of the bed frame that moves when the head of the bed is adjusted.Answer
  3. Ensure that two fingers can comfortably fit between the restraint device and the client's wrist.Answer
  4. D
    Delegate the hourly assessment of the client's peripheral pulses and skin temperature to the assistive personnel (AP).
  5. E
    Secure the restraint ties to the side rails of the bed using a quick-release slip knot.
  6. F
    Verify that the provider has written a PRN (as needed) prescription for the restraints to use during periods of worsening confusion.

Answer

The correct actions are removing the restraints every 2 hours for skin care, attaching the straps to a movable part of the bed frame, and ensuring two fingers fit between the restraint and the wrist.
Safe restraint application requires strict adherence to safety protocols: regular removal (every 2 hours) is essential to prevent skin breakdown and maintain joint mobility. Securing the straps to the movable part of the bed frame prevents hazardous tightening when the bed is adjusted. Allowing a two-finger gap ensures that arterial and venous circulation is maintained while keeping the restraint functional.

Step-by-Step Solution

1
Evaluate the requirement for routine restraint release.
Identify that restraints must be removed at least every 2 hours.
This action prevents skin breakdown, contractures, and allows for thorough neurovascular assessment.
2
Determine the proper anatomical and structural location for securing the restraint.
Identify that straps must be tied to the movable part of the bed frame, not side rails.
Securing to side rails causes injury if the rails are dropped; securing to a movable frame ensures the restraint moves safely with the client's body position.
3
Verify the correct tightness of the applied restraint.
Identify that a two-finger gap is the required standard.
This specific measurement ensures the restraint is tight enough to prevent escape but loose enough to maintain peripheral perfusion.
4
Analyze the incorrect actions for legal and scope-of-practice violations.
Rule out delegating assessments, tying to side rails, and PRN prescriptions.
Assessments cannot be delegated, side rails are a severe safety hazard, and PRN orders for restraints are legally prohibited.

Key Concept

Safe application, monitoring, and legal parameters of physical restraints.
Estimated Time:2m 0s
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Topics

Use of Restraints and Safety Devices

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