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Difficulty: MediumUse of Restraints and Safety Devices

A 79-year-old client with a central venous catheter is currently in bilateral soft wrist restraints to prevent device disruption. When managing this client's ongoing care, which action by the practical nurse (PN) demonstrates adherence to safety and legal standards?

  1. Releasing the restraints one limb at a time every two hours to evaluate skin integrity and provide range-of-motion exercises.Answer
  2. B
    Implementing a provider prescription that directs applying the restraints as needed (PRN) whenever the client exhibits agitation.
  3. C
    Conducting an initial comprehensive neurological assessment to establish the primary etiology of the client's confusion.
  4. D
    Attributing the sudden onset of severe agitation to normal age-related cognitive decline without investigating further.

Answer

Releasing the restraints one limb at a time every two hours to evaluate skin integrity and provide range-of-motion exercises.
Safe and effective restraint management requires continuous monitoring and regular release to prevent serious physical complications. Releasing the restraints one limb at a time every two hours allows the nurse to assess neurovascular status, check skin integrity, and perform range-of-motion exercises without completely compromising the client's safety or allowing them to remove their central venous catheter.

Step-by-Step Solution

1
Analyze the scenario focusing on the maintenance and legal guidelines of physical restraints.
The nurse must prioritize interventions that prevent physical complications (like skin breakdown or compromised circulation) while respecting scope of practice and legal boundaries.
Restraints pose a high risk for injury and legal liability if not managed according to strict clinical standards.
2
Evaluate the option regarding PRN prescriptions.
This action is rejected because PRN orders for restraints are universally prohibited by regulatory agencies.
Each episode of restraint application requires a distinct clinical justification and a specific, time-limited order.
3
Evaluate the options regarding comprehensive assessment and age-related decline.
Both are rejected. The comprehensive assessment exceeds the PN's scope of practice, and acute agitation is a sign of delirium, not normal aging.
PNs perform focused data collection rather than initial diagnostic assessments, and acute confusion always warrants medical investigation.
4
Select the option describing restraint release every two hours.
This is identified as the correct and safe action.
Releasing restraints sequentially every 2 hours is the standard evidence-based practice to maintain skin integrity and neurovascular health.

Key Concept

Restraint Monitoring and Legal Guidelines
Estimated Time:1m 0s
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Topics

Use of Restraints and Safety Devices

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