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Difficulty: MediumUse of Restraints and Safety Devices

An older adult client is admitted to the medical-surgical unit with a severe infection. During the night, the client develops acute confusion and repeatedly attempts to climb out of bed unassisted. The healthcare provider prescribes a vest restraint. Which of the following nursing actions should the practical nurse (PN) implement? (Select all that apply.)

  1. Secure the restraint straps to the movable portion of the bed frame using a quick-release tie.Answer
  2. Release the restraint at least every 2 hours to provide skin care, toileting, and range-of-motion exercises.Answer
  3. C
    Implement the prescribed restraint immediately before attempting less restrictive safety measures.
  4. D
    Assign the unlicensed assistive personnel (UAP) to independently evaluate the client's respiratory status and skin integrity.
  5. E
    Reassure the client's family that the sudden onset of confusion is a normal part of the aging process that necessitates physical restraint.

Answer

The correct actions are to secure the restraint to the movable portion of the bed frame with a quick-release tie and to release the restraint every 2 hours for care and assessment.
The correct actions involve prioritizing client safety through proper restraint application and routine monitoring. Securing the straps to the movable portion of the bed frame ensures the restraint does not tighten if the head or foot of the bed is adjusted, while a quick-release tie allows for rapid emergency access. Releasing the restraint at least every 2 hours is a mandatory standard of practice to assess skin integrity, perform range-of-motion exercises, and meet basic physiological needs.

Step-by-Step Solution

1
Analyze the prescribed intervention (vest restraint) and identify safe application techniques.
Recognize that restraints must be tied to the movable bed frame with a quick-release knot.
This prevents patient injury during bed adjustments and allows rapid removal in emergencies.
2
Determine the required ongoing care and monitoring for a restrained client.
Identify the need to release restraints every 2 hours for skin care, toileting, and range-of-motion.
Regular release prevents complications such as skin breakdown, contractures, and poor circulation.
3
Evaluate the remaining options against legal and scope-of-practice standards.
Eliminate options that bypass less restrictive alternatives, delegate nursing assessments to UAPs, or mischaracterize acute confusion.
These actions violate the principles of least restrictive care, safe delegation, and accurate clinical knowledge.

Key Concept

Safe application and monitoring of physical restraints, including the mandatory use of least restrictive alternatives and appropriate delegation.
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Topics

Use of Restraints and Safety Devices

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