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Difficulty: MediumUse of Restraints and Safety Devices

A 78-year-old client with pneumonia is admitted to the medical-surgical unit and begins exhibiting signs of acute confusion, repeatedly attempting to climb over the bed rails. The healthcare provider evaluates the client and prescribes a physical vest restraint. Which actions are appropriate for the practical nurse (PN) to include in the plan of care? Select all that apply.

  1. Secure the restraint ties to the stationary portion of the bed frame using a quick-release knot.Answer
  2. Verify that two fingers can comfortably slide between the vest restraint and the client's chest.Answer
  3. Release the restraint at least every 2 hours to perform range-of-motion exercises and assess skin integrity.Answer
  4. D
    Apply the restraint immediately upon receiving the prescription before evaluating the effectiveness of a bed alarm.
  5. E
    Request the provider to change the prescription to a PRN (as needed) order for use only during severe agitation.
  6. F
    Attribute the client's acute confusion to normal age-related cognitive decline rather than a potential complication of the infection.

Answer

The appropriate actions are to secure the restraint to a stationary bed frame with a quick-release knot, ensure a two-finger gap between the restraint and the client's chest, and release the restraint every 2 hours for assessment and care.
Proper and safe use of a physical restraint requires attaching the straps to a non-movable part of the bed frame (never the side rails) using a quick-release knot to allow for rapid removal. The nurse must verify that two fingers fit under the restraint to prevent impaired breathing or circulation. Furthermore, standard of care dictates that physical restraints must be released at least every 2 hours to provide skin care, assess neurovascular status, and allow for range-of-motion exercises.

Step-by-Step Solution

1
Analyze the clinical scenario and the prescription.
The client has a valid provider prescription for a vest restraint due to acute confusion and safety risks.
Establishing the clinical foundation is required to determine appropriate nursing interventions.
2
Identify safe physical restraint application mechanics.
The vest restraint must be tied to a stationary frame with a quick-release knot, allowing two fingers of space.
This prevents asphyxiation and mechanical injury while ensuring rapid removal in a clinical emergency.
3
Determine ongoing monitoring and care requirements.
The restraint must be released at least every 2 hours for skin care, toileting, and range-of-motion exercises.
Continuous monitoring prevents complications such as skin breakdown and neurovascular compromise.
4
Evaluate remaining distractors for unsafe or illegal practices.
PRN orders, bypassing less restrictive alternatives, and normalizing acute confusion are identified as critical safety errors.
Eliminating choices that violate legal boundaries and standard clinical guidelines ensures safe client care.

Key Concept

Physical restraints require strict adherence to application safety (stationary frame, quick-release knot, two-finger gap), continuous monitoring (release every 2 hours), and legal parameters (no PRN orders, mandatory trial of alternatives).
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Topics

Use of Restraints and Safety Devices

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