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Zorluk: OrtaUse of Restraints and Safety Devices

A practical nurse (PN) is participating in the care of a client who is agitated and repeatedly attempting to remove their life-saving continuous positive airway pressure (CPAP) mask. The nursing team is developing a plan to manage the client's safety. Which of the following actions regarding the use of physical restraints should the PN identify as appropriate? (Select all that apply)

  1. Secure the restraint straps to a movable portion of the client's bed frame.Cevap
  2. Ensure that two fingers can easily slide between the restraint and the client's wrist.Cevap
  3. C
    Apply the restraints immediately at the first sign of restlessness to prevent the mask from being removed.
  4. D
    Obtain a PRN (as needed) prescription from the healthcare provider to use restraints during nighttime shifts.
  5. Release the restraints one limb at a time every 2 hours to provide skin care and perform range-of-motion exercises.Cevap
  6. F
    Assign the assistive personnel (AP) to evaluate whether the client's behavior warrants continued use of the restraints.

Cevap

The correct actions are securing the straps to a movable part of the bed frame, ensuring a two-finger fit, and releasing the restraints every 2 hours for care.
Securing restraints to a movable part of the bed frame prevents injury when the bed's position changes. Ensuring a two-finger gap prevents circulatory impairment and nerve damage. Releasing restraints every 2 hours is a mandatory standard of care to assess skin integrity, perform range-of-motion exercises, and ensure basic needs are met.

Adım Adım Çözüm

1
Identify the principles of safe physical restraint application and monitoring.
Safe application requires tying straps to movable bed parts, verifying a two-finger fit, and systematically removing restraints for care.
These specific actions prevent accidental injury, neurovascular compromise, and skin breakdown during restraint use.
2
Recognize the legal and ethical regulations governing restraint prescriptions.
PRN (as needed) orders for restraints are strictly prohibited, and less restrictive measures must always be attempted first.
Restraints are interventions of last resort, and strict regulations protect client rights and prevent unnecessary physical restriction.
3
Apply the principles of safe delegation regarding restraint management.
The assessment of a client's ongoing need for restraints cannot be delegated to assistive personnel (AP).
Evaluation of clinical status requires licensed nursing judgment and falls outside the AP's scope of practice.

Anahtar Kavram

Principles of Safe Restraint Use, Application, and Delegation
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Konular

Use of Restraints and Safety Devices

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