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Question

Difficulty: MediumUse of Restraints and Safety Devices

A 55-year-old client recovering from a thyroidectomy becomes confused and repeatedly attempts to pull at their surgical neck incision. Which actions are appropriate for the practical nurse (PN) to take regarding client safety and the potential use of restraints? Select all that apply.

  1. Attempt less restrictive alternatives, such as providing a distracting activity or engaging a sitter, before considering physical restraints.Answer
  2. Secure the restraint straps to the movable portion of the bed frame using quick-release knots, if a physical restraint is prescribed.Answer
  3. C
    Apply bilateral wrist restraints immediately to ensure the surgical incision remains intact and free from infection.
  4. D
    Accept a delegated task from the registered nurse to independently assess and determine when the restraints can be discontinued.

Answer

The correct actions are to attempt less restrictive alternatives before considering restraints and to secure any prescribed restraint straps to the movable portion of the bed frame using quick-release knots.
Attempting less restrictive alternatives is legally and ethically required before using physical restraints. When restraints are unavoidable, securing them to the movable portion of the bed frame with quick-release knots ensures client safety during bed adjustments and allows rapid removal during emergencies.

Step-by-Step Solution

1
Evaluate the clinical scenario to identify the primary safety concern.
The client is confused and at risk of disrupting a surgical incision.
Identifying the safety risk dictates the level of intervention required.
2
Determine the appropriate first-line interventions for an agitated client.
Less restrictive alternatives, such as providing distraction or a sitter, must be utilized first.
Restraints are a last resort due to the potential for physical and psychological harm.
3
Review the standards for safe restraint application.
If applied, restraints must be tied to the movable part of the bed frame with quick-release knots.
This ensures the restraints move with the client when the bed is adjusted, preventing injury, and allows for emergency removal.
4
Analyze the scope of practice for the practical nurse (PN) regarding restraints.
The PN cannot independently evaluate the clinical readiness for restraint discontinuation.
This task requires complex clinical judgment and RN-level assessment.

Key Concept

Restraint Safety and Scope of Practice
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Topics

Use of Restraints and Safety Devices

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