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Difficulty: MediumSafe Use of Restraints and Safety Devices

A clinical nurse educator is evaluating a newly licensed nurse who is caring for an older adult client with bilateral soft wrist restraints. The restraints were applied to prevent the client from dislodging a continuous bladder irrigation (CBI) catheter. Which action by the newly licensed nurse indicates a correct understanding of regulatory and safety protocols for restraint management?

  1. Confirming that the physical restraint prescription is strictly time-limited to a 24-hour maximum and is not written as a PRN (as needed) order.Answer
  2. B
    Tying the restraint straps to the bed's movable frame utilizing a tight square knot to prevent the client from loosening them.
  3. C
    Assigning the unlicensed assistive personnel to evaluate and document the client's distal pulses and skin integrity every two hours.
  4. D
    Securing the restraint ties directly to the adjustable siderails to maintain maximum distance from the catheter site.

Answer

The correct action is ensuring the restraint prescription is time-limited to 24 hours and is not a PRN order.
The correct answer demonstrates adherence to strict regulatory standards for restraint use. For non-violent, medical-surgical applications, a healthcare provider's prescription is only valid for a maximum of 24 hours. Furthermore, restraints can never be prescribed as a PRN (as needed) order; a new, specific prescription must be obtained each time restraints are initiated or renewed.

Step-by-Step Solution

1
Identify the primary focus of the clinical scenario.
The scenario focuses on the safe, legal management of non-violent, medical-surgical restraints used to prevent medical device (CBI catheter) dislodgment.
Different types of restraints (behavioral vs. medical-surgical) have distinct regulatory protocols.
2
Recall the federal and clinical regulations governing restraint prescriptions.
Restraints must have a specific, time-limited order (typically 24 hours for medical-surgical use) and PRN (as needed) orders are explicitly forbidden.
This prevents clients from being unnecessarily restrained and ensures continuous medical re-evaluation.
3
Evaluate the safety of the mechanical application described in the incorrect options.
Restraints must be tied with quick-release knots to the movable portion of the bed frame to prevent injury and allow rapid emergency removal.
Square knots delay removal in emergencies, and tying to siderails can cause severe musculoskeletal injury.
4
Analyze the delegation of tasks mentioned in the options.
Routine observation can be delegated, but any task requiring clinical assessment, such as checking neurovascular status, must be performed by the registered nurse.
Assessments fall strictly within the registered nurse's scope of practice.

Key Concept

Safe Use of Restraints and Safety Devices
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Topics

Safe Use of Restraints and Safety Devices

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