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Zorluk: KolayUse of Restraints and Safety Devices

A practical nurse is caring for a client who repeatedly attempts to pull out a newly placed nasogastric feeding tube. A healthcare provider has prescribed bilateral soft wrist restraints. Which actions are required to ensure the safe use of these devices? Select all that apply.

  1. Remove the restraints at least every two hours to provide skin care and range-of-motion exercises.Cevap
  2. Fasten the restraint straps to the movable part of the bed frame using a quick-release knot.Cevap
  3. C
    Apply the physical devices immediately when the client touches the tube, before attempting to conceal the tubing.
  4. D
    Delegate the evaluation of the client's skin integrity and circulation to the assistive personnel.
  5. Verify that two fingers can easily slide between the client's wrist and the secured material.Cevap

Cevap

The correct actions include removing the restraints at least every two hours, fastening the straps to the movable part of the bed frame, and verifying that two fingers can fit beneath the secured material.
Safe application and maintenance of physical restraints require three key interventions: attaching the straps to the movable portion of the bed frame to avoid injury during bed adjustments, checking that two fingers fit underneath to confirm circulation is not impaired, and releasing the restraints every two hours to monitor skin integrity and perform range-of-motion exercises.

Adım Adım Çözüm

1
Identify the core requirements for safe physical restraint application.
Recognize that restraints require regular monitoring, proper anchoring, and correct sizing to prevent injury.
Physical restraints can cause severe neurovascular compromise or mechanical injury if applied incorrectly.
2
Evaluate the clinical appropriateness of the nursing interventions.
Determine that assessing for a two-finger gap, removing the devices every two hours, and using the movable bed frame are safe, evidence-based practices.
These actions directly maintain circulation, prevent skin breakdown, and prevent accidental injury if bed positioning changes.
3
Rule out actions that violate the scope of practice or restraint protocols.
Identify that bypassing least-restrictive alternatives and delegating assessments to assistive personnel are incorrect actions.
Nurses must always attempt alternatives first, and the evaluation of circulation is an assessment that cannot be delegated.

Anahtar Kavram

Safe Application and Monitoring of Physical Restraints
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Konular

Use of Restraints and Safety Devices

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