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Difficulty: MediumSafe Use of Restraints and Safety Devices

A nurse in an intensive care unit is caring for a client who is intubated and mechanically ventilated. The client is experiencing acute agitation and repeatedly grasps at the endotracheal tube. After determining that verbal de-escalation and therapeutic touch are insufficient to maintain airway safety, the nurse obtains a prescription for bilateral soft wrist restraints. Which action should the nurse take to ensure proper safety and compliance with restraint protocols?

  1. Fasten the restraint ties to the movable portion of the bed frame using a quick-release knot.Answer
  2. B
    Request a PRN (as-needed) prescription from the healthcare provider to manage intermittent episodes of severe agitation.
  3. C
    Delegate the ongoing assessment of the client's peripheral pulses and skin integrity to the unlicensed assistive personnel (UAP).
  4. D
    Release the restraints once every 8 hours to perform passive range-of-motion exercises and inspect the skin.

Answer

Fasten the restraint ties to the movable portion of the bed frame using a quick-release knot.
To ensure client safety, restraint straps must always be secured to the movable portion of the bed frame. This prevents the restraint from tightening, pulling, or causing injury when the head or foot of the bed is raised or lowered. Additionally, a quick-release knot (slip knot) is mandatory so that healthcare providers can remove the restraints immediately in the event of an emergency, such as a code blue or fire.

Step-by-Step Solution

1
Identify the regulatory and safety requirements for applying physical restraints in a critical care setting.
Physical restraints must be safe, easily removable in an emergency, and strictly monitored to prevent neurovascular and skin complications.
Improper application can lead to severe injury, circulation impairment, or inability to perform life-saving interventions.
2
Evaluate the proposed nursing actions against evidence-based safety standards.
Tying restraints to a movable bed frame with a quick-release knot aligns with safety standards, while PRN orders, infrequent removal, and improper delegation violate core protocols.
To select the single correct action that demonstrates safe and effective care.

Key Concept

Safe Restraint Application and Monitoring Protocols
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Topics

Safe Use of Restraints and Safety Devices

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