Following an emergency endotracheal intubation, a client requires bilateral soft wrist restraints to prevent unplanned extubation. Which nursing action demonstrates the correct management of these safety devices?
- Releasing one restraint at a time every two hours to perform skin care and range-of-motion exercises.Answer
- BFastening the restraint straps securely to the bed's side rails using a quick-release knot.
- CDelegating the hourly evaluation of the client's capillary refill and radial pulses to the unlicensed assistive personnel.
- DRequesting a PRN (as-needed) prescription for the restraints to use if the client becomes increasingly agitated.
Answer
The correct action is to release one restraint at a time every two hours to perform skin care and range-of-motion exercises.
To maintain client safety and prevent physiological complications such as skin breakdown or contractures, medical restraints must be released at least every 2 hours. In critically ill clients with life-sustaining equipment, such as an endotracheal tube, the nurse must release only one restraint at a time. This ensures that the client's skin and joints receive care without providing them the opportunity to use a free hand to dislodge the tube.
Step-by-Step Solution
Key Concept
Safe Restraint Management and Delegation