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Difficulty: EasySafe Use of Restraints and Safety Devices

A nurse is implementing care for a client who currently requires physical wrist restraints to prevent interference with a newly inserted percutaneous endoscopic gastrostomy (PEG) tube. Which of the following interventions must the nurse include in the client's plan of care? Select all that apply.

  1. Attach the restraint straps to the movable portion of the bed frame.Answer
  2. B
    Secure the restraint straps to the bed's side rails using a standard square knot.
  3. Remove the restraints at least every 2 hours to provide skin care and range-of-motion exercises.Answer
  4. D
    Obtain a PRN (as-needed) prescription for the restraints from the primary healthcare provider.
  5. E
    Delegate the ongoing evaluation of the client's behavioral status to the unlicensed assistive personnel (UAP).
  6. Document the specific client behaviors that indicate the continued need for the restraints.Answer

Answer

The correct interventions are attaching the straps to the movable portion of the bed frame, removing the restraints at least every 2 hours for care, and documenting specific behaviors indicating the continued need for restraints.
Safe restraint use mandates attaching straps to the movable part of the bed frame to prevent traction injury during bed adjustments, removing them at least every 2 hours to ensure circulation and joint mobility, and maintaining strict documentation of the behaviors justifying their ongoing use.

Step-by-Step Solution

1
Identify the core subject of the scenario.
The scenario requires selecting safe, legally compliant, and standard nursing interventions for a client with physical restraints.
Recognizing the guidelines for restraint use dictates the correct actions and prevents patient harm.
2
Evaluate each option based on established safety protocols.
Attaching to a movable frame, providing care every 2 hours, and documenting specific behaviors are standard safe practices.
These actions protect the client from mechanical injury, physiological compromise, and ensure legal justification for the restraints.
3
Identify contraindicated actions and unsafe practices in the remaining options.
Tying restraints to side rails, using square knots, relying on PRN orders, and delegating assessment to UAP are identified as dangerous or legally impermissible.
Side rails move independently and can cause severe injury; square knots delay emergency removal; PRN orders are legally banned; and assessments require registered nurse judgment.

Key Concept

Standard safety protocols, legal guidelines, and proper delegation regarding the use of physical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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