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Difficulty: EasySafe Use of Restraints and Safety Devices

A client in the intensive care unit is intubated and requires bilateral soft wrist restraints to prevent the dislodgment of the endotracheal tube. The healthcare provider has written the initial prescription. Which of the following nursing actions are appropriate? Select all that apply.

  1. A
    Request a prescription from the healthcare provider for the restraints to be applied as needed (PRN) for agitation.
  2. Tie the straps to the bed frame using a slip knot that can be untied quickly in an emergency.Answer
  3. C
    Assign the routine evaluation of the client's skin color and capillary refill to the nursing assistant.
  4. Ensure that exactly two fingers can be easily inserted between the client's wrist and the restraint.Answer
  5. E
    Attach the restraint ties directly to the bed's side rails to keep the arms immobilized.
  6. Remove the restraints one at a time every two hours to provide skin care and range of motion exercises.Answer

Answer

The appropriate actions are tying the straps to the bed frame with a quick-release knot, ensuring a two-finger gap under the restraint, and removing the restraints every two hours for skin care.
Safe restraint application requires tying the device to a non-moving part of the bed frame using a quick-release (slip) knot so it can be removed immediately in an emergency. The nurse must also verify that two fingers can fit under the restraint to prevent neurovascular compromise. Additionally, for non-violent medical restraints, the nurse must release them at least every two hours to perform range of motion exercises, provide skin care, and assess basic needs.

Step-by-Step Solution

1
Identify the legal and safety guidelines for physical restraint application.
Restraints require continuous safety checks, specific application techniques to avoid injury, and proper documentation.
Restraints pose a high risk for injury and rights violations if applied incorrectly.
2
Evaluate each provided nursing action for safety and compliance with standards.
Slip knots, two-finger gaps, and two-hour removals are standard safe practices. PRN orders, side rail attachments, and delegating assessments violate safety standards.
To differentiate between correct evidence-based interventions and unsafe practices.
3
Select all actions that represent safe and legal nursing practice.
Three distinct interventions are verified as correct nursing practice.
The question requires identifying all correct applications of the safety protocols.

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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