Examkin

Question

Difficulty: MediumSafe Use of Restraints and Safety Devices

The unit educator is observing a newly licensed nurse provide care for a confused client who requires bilateral soft wrist restraints to prevent the removal of a central venous catheter. Which action by the newly licensed nurse indicates a need for immediate intervention by the educator?

  1. A
    Assigning the unlicensed assistive personnel to feed the client and assist with repositioning when the ties are loosened.
  2. Securing the restraint ties to the side rails of the bed using a square knot.Answer
  3. C
    Temporarily removing one device at a time on a two-hour schedule to check skin integrity and perform passive joint movements.
  4. D
    Charting the previous unsuccessful attempts to use bed alarms and frequent reorientation before obtaining the prescription.

Answer

The action that requires immediate intervention is securing the restraint ties to the side rails of the bed using a square knot.
The action of tying restraints to the side rails using a square knot is fundamentally unsafe and requires immediate intervention by the educator. Restraints must always be attached to the movable portion of the bed frame to prevent traumatic injury if the bed position is changed or the side rail is lowered. Furthermore, a quick-release knot (such as a slip knot) must be used rather than a square knot to ensure the restraints can be rapidly removed in the event of an emergency.

Step-by-Step Solution

1
Analyze the clinical scenario and the specific question being asked.
The question requires identifying the unsafe action (the action needing intervention) during restraint management.
Understanding whether you are looking for a correct or incorrect nursing intervention is critical for selecting the right answer.
2
Evaluate the method of restraint application described in the options.
Tying restraints to a side rail or using a square knot poses severe safety risks, such as injury when the bed is adjusted or inability to remove the restraint rapidly in an emergency.
CMS and NCLEX standards dictate that restraints must be secured to the movable portion of the bed frame using a quick-release knot.
3
Evaluate the delegated tasks and maintenance protocols.
Assigning ADLs to a UAP, releasing restraints every two hours, and documenting prior alternatives are all mandated, safe standards of care.
Eliminating the safe actions isolates the single unsafe practice.
4
Select the option that represents the protocol violation.
The improper application technique is identified as the required intervention.
This directly answers the prompt's request to find the action needing correction.

Key Concept

Safe Application and Maintenance of Physical Restraints
Rate this question

Topics

Safe Use of Restraints and Safety Devices

More questions from this topic