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Difficulty: EasySafe Use of Restraints and Safety Devices

A registered nurse is providing care to a client with a traumatic brain injury who repeatedly attempts to dislodge a newly inserted nasogastric tube. After securing a provider's prescription for physical limb restraints, which action should the nurse take to ensure client safety?

  1. Fasten the restraint straps to the movable segment of the bed frame using a quick-release knot.Answer
  2. B
    Secure the restraint straps directly to the bed's side rails to keep them easily accessible.
  3. C
    Apply the prescribed device before documenting the failure of less restrictive interventions.
  4. D
    Delegate the initial evaluation of the client's peripheral pulses and skin integrity to the unlicensed assistive personnel.

Answer

The correct action is to fasten the restraint straps to the movable segment of the bed frame using a quick-release knot.
Fastening the restraint straps to the movable segment of the bed frame using a quick-release knot ensures that the restraints move simultaneously with the client when the head or foot of the bed is adjusted. This prevents unintended tension and injury. Furthermore, the quick-release knot allows healthcare providers to remove the device instantly during an emergency.

Step-by-Step Solution

1
Analyze the principles of safe physical restraint application.
Restraints must be secured in a way that prevents injury during bed movement and allows for rapid release.
Improperly secured restraints can cause musculoskeletal damage or delay life-saving care during an emergency.
2
Evaluate the placement location for the restraint straps.
Straps must be attached to the movable portion of the bed frame, never to the side rails.
If tied to the side rails, lowering the rails will forcefully pull the client's limb, causing injury.
3
Identify the correct knot technique.
A quick-release knot (slip knot) must be used.
This specific knot ensures the device can be untied instantly in case of a medical emergency.

Key Concept

Safe application and securing of physical restraints
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Topics

Safe Use of Restraints and Safety Devices

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