Examkin

Question

Difficulty: MediumUse of Restraints and Safety Devices

During a night shift, a practical nurse (PN) is assigned to care for an 85-year-old client who recently underwent an exploratory laparotomy. The client is experiencing acute disorientation, attempting to remove a nasogastric (NG) tube, and soft wrist restraints have been prescribed after less restrictive measures failed. Which of the following nursing actions are appropriate for this client? (Select all that apply.)

  1. Fasten the restraint straps to the movable portion of the bed frame using a quick-release knot.Answer
  2. Remove the restraints one at a time every 2 hours to perform range-of-motion exercises.Answer
  3. C
    Request a PRN (as-needed) prescription for the restraints to allow for prompt reapplication if the client's agitation worsens.
  4. D
    Attribute the sudden onset of disorientation to a normal age-related cognitive change following major surgery.
  5. Verify that two fingers can be easily inserted between the restraint and the client's skin.Answer
  6. F
    Assign the unlicensed assistive personnel (UAP) to evaluate the client's ongoing need for the restraints.

Answer

The correct actions include fastening the straps to the movable bed frame using a quick-release knot, removing the restraints every 2 hours for care and assessment, and ensuring two fingers can comfortably fit between the restraint and the skin.
The correct nursing actions prioritize client safety and adherence to legal guidelines. Fastening the restraint to the movable portion of the bed frame ensures the restraint moves with the client when the bed is adjusted, preventing injury. Using a quick-release knot allows for rapid removal in an emergency. Removing the restraints every 2 hours to perform range-of-motion exercises and check skin integrity is required to prevent neurovascular compromise and skin breakdown. Verifying that two fingers can fit under the restraint ensures it is not applied too tightly, protecting circulation.

Step-by-Step Solution

1
Evaluate the legal and clinical requirements for restraint orders and delegation.
Identified that PRN orders are prohibited and that assessing the need for restraints cannot be delegated to a UAP.
Restraints involve strict regulations and require licensed nursing judgment to protect client rights and safety.
2
Determine the correct mechanical application of the physical restraints.
Confirmed that tying the straps to a movable bed frame with a quick-release knot and leaving two fingers of space is required.
These specific mechanics prevent injury during bed adjustments, allow for rapid emergency release, and ensure adequate circulation.
3
Identify ongoing monitoring and care needs for the client experiencing delirium.
Recognized the need to release restraints every 2 hours for skin care and range-of-motion exercises, while investigating the acute confusion rather than dismissing it as age-related.
Continuous monitoring prevents physical complications, and recognizing delirium as abnormal prompts the search for underlying causes like hypoxia or infection.

Key Concept

Use of Restraints and Safety Devices
Rate this question

Topics

Use of Restraints and Safety Devices

More questions from this topic