Difficulty: Medium
Average Score: 75%
Simulated
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
Correct answer
A,B,D
Rationale
Correct Answer: A, B, D
Rationale:
A: Ensuring the clientÔÇÖs bed is in the lowest position prevents falls and minimizes injury risk if the client tries to get out of bed.
B: Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
D: Padding bony prominences before applying restraints prevents pressure ulcers and discomfort for the client.
Summary:
C: Attaching the restraints to the bed rail can increase the risk of injury if the client moves around.
E: Allowing three fingers to slide under the restraints is incorrect as it can lead to improper fit and ineffective restraint.
Rationale:
A: Ensuring the clientÔÇÖs bed is in the lowest position prevents falls and minimizes injury risk if the client tries to get out of bed.
B: Assessing skin temperature and color before applying restraints ensures proper circulation and skin integrity.
D: Padding bony prominences before applying restraints prevents pressure ulcers and discomfort for the client.
Summary:
C: Attaching the restraints to the bed rail can increase the risk of injury if the client moves around.
E: Allowing three fingers to slide under the restraints is incorrect as it can lead to improper fit and ineffective restraint.