Examkin

Soru

Zorluk: KolaySafe Use of Restraints and Safety Devices

A client on a medical-surgical unit is confused and continuously attempts to get out of bed, posing a significant risk for falls. Which action should the nurse implement first as a less restrictive alternative to a physical restraint?

  1. Activating a weight-sensitive bed alarm to alert staff when the client attempts to exit the bedCevap
  2. B
    Elevating all four side rails on the bed to physically prevent the client from getting up
  3. C
    Delegating an unlicensed assistive personnel to assess the underlying cause of the client's confusion
  4. D
    Contacting the healthcare provider to request a PRN (as-needed) prescription for wrist restraints

Cevap

Activating a weight-sensitive bed alarm to alert staff when the client attempts to exit the bed
The correct action demonstrates the use of a less restrictive alternative. A bed alarm promotes safety by notifying staff of movement without confining the client or restricting their physical freedom.

Adım Adım Çözüm

1
Analyze the client's situation and the goal of care.
The confused client is at risk for falls, and the goal is to maintain safety using the least restrictive measures possible.
Nursing standards dictate that physical and chemical restraints are interventions of last resort.
2
Evaluate the provided options to identify the intervention that maintains safety without restricting movement.
Using a bed alarm provides early warning to staff without restraining the client, whereas raising four side rails is considered a restraint.
Bed alarms meet the legal and ethical criteria for a less restrictive alternative to physical restraints.

Anahtar Kavram

Less Restrictive Alternatives to Restraints
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Konular

Safe Use of Restraints and Safety Devices

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