Difficulty: Medium
Average Score: 76%
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?
Correct answer
A,C,D
Rationale
The correct actions are A, C, and D.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.
A: Assessing skin temperature and color before applying restraints helps prevent skin breakdown.
C: Ensuring the bed is in the lowest position reduces fall risk and injury.
D: Padding bony prominences prevents pressure injuries.
B: Attaching restraints to the bed rail can cause harm if the client moves.
E: Allowing three fingers under restraints is too loose and can lead to escape or injury.