Difficulty: Medium
Average Score: 62%
Simulated
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan?
Correct answer
A,,B,D,E
Rationale
Correct Answer: A, B, D, E
Rationale:
A: Ensuring two fingers can fit between the device and the client prevents constriction and maintains circulation.
B: Performing neurovascular checks every 2 hours helps assess circulation and nerve function, crucial for preventing complications.
D: Obtaining a prescription renewal every 72 hours is necessary to ensure the restraint's continued use is justified.
E: Implementing passive range-of-motion exercises prevents contractures and maintains joint mobility, crucial for an immobile client's well-being.
Summary:
C: Securing the restraint to the bedrail can increase the risk of injury and is not recommended.
F:
G:
Choices C, F, and G are not included in the correct answer as they do not directly address the safety and well-being of the immobile client in a mitten restraint.
Rationale:
A: Ensuring two fingers can fit between the device and the client prevents constriction and maintains circulation.
B: Performing neurovascular checks every 2 hours helps assess circulation and nerve function, crucial for preventing complications.
D: Obtaining a prescription renewal every 72 hours is necessary to ensure the restraint's continued use is justified.
E: Implementing passive range-of-motion exercises prevents contractures and maintains joint mobility, crucial for an immobile client's well-being.
Summary:
C: Securing the restraint to the bedrail can increase the risk of injury and is not recommended.
F:
G:
Choices C, F, and G are not included in the correct answer as they do not directly address the safety and well-being of the immobile client in a mitten restraint.