Difficulty: Medium
Average Score: 88%
Simulated
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Correct answer
C
Rationale
The correct answer is C, to secure the restraints using a quick-release tie. This is important for safety reasons as it allows for quick removal in case of an emergency. Securing the restraints to the lowest bar of the side rail (choice A) is incorrect as it can lead to injury if the client attempts to get out of bed. Ensuring four fingers fit under the restraints (choice B) is incorrect as it can still lead to constriction. Anticipating removing the restraints every 4 hours (choice D) is incorrect as restraints should be removed and repositioned every 2 hours to prevent skin breakdown.