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Question

Difficulty: HardUse of Restraints and Safety Devices

An older adult client with no prior cognitive deficits is admitted to the medical unit for treatment of a severe infection. On the second day of admission, the client suddenly develops acute confusion, becomes highly agitated, and repeatedly attempts to climb over the bed rails. After multiple non-pharmacological interventions prove ineffective, the provider prescribes bilateral soft wrist restraints. Which action by the practical nurse (PN) demonstrates safe and legally compliant management of the client's restraints?

  1. Attaching the restraint ties to the movable section of the bed frame using a quick-release slip knot.Answer
  2. B
    Asking the provider to format the prescription as 'PRN (as needed) for agitation' to facilitate rapid reapplication if necessary.
  3. C
    Assigning the ongoing evaluation of the client's capillary refill, skin temperature, and distal pulses to the unlicensed assistive personnel (UAP).
  4. D
    Attributing the sudden agitation to the client's advanced age and proceeding with the restraint application without investigating for underlying causes.

Answer

The correct action is attaching the restraint ties to the movable section of the bed frame using a quick-release slip knot.
Securing restraints to the movable portion of the bed frame ensures that the straps move synchronously with the client when the head or foot of the bed is raised or lowered, preventing accidental tightening and injury. Utilizing a quick-release slip knot is a critical safety standard, allowing healthcare personnel to remove the restraints instantly in the event of a fire, seizure, or cardiac arrest.

Step-by-Step Solution

1
Analyze the legal and safety requirements for applying and maintaining physical restraints in an inpatient setting.
Identifies that restraints must be secured in a way that prevents patient injury during bed movement and allows for immediate emergency removal.
Safety devices must not introduce new hazards, such as strangulation or restricted peripheral blood flow.
2
Evaluate the restraint prescription guidelines and the boundaries of nursing delegation.
Recognizes that PRN orders for restraints are universally illegal and that neurovascular assessments are beyond the UAP's scope of practice.
Regulatory standards mandate continuous evaluation for alternatives, and assessing physiological status requires a licensed nurse's clinical judgment.
3
Select the option that aligns with established safety protocols for restraint application.
Chooses the option detailing attachment to the movable bed frame with a slip knot.
This is the only intervention that correctly reflects safe, legally compliant restraint application principles.

Key Concept

Physical Restraint Safety, Legal Regulations, and Delegation Scope
Estimated Time:1m 30s
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Topics

Use of Restraints and Safety Devices

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