Difficulty: Medium
Average Score: 66%
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 is crucial to prevent circulation impairment or skin breakdown.
B: Performing a neurovascular check every 2 hours is essential to monitor for any signs of impaired circulation or nerve damage.
D: Obtaining a prescription renewal every 72 hours ensures that the use of restraints is reviewed regularly and necessary adjustments can be made.
E: Implementing passive range-of-motion exercises helps prevent contractures and maintain joint mobility in immobile clients.
Summary:
C: Securing the restraint to the bedrail can pose a safety risk and restrict mobility, which is not recommended.
F and G: No choices provided.
Rationale:
A: Ensuring two fingers can fit between the device and the client is crucial to prevent circulation impairment or skin breakdown.
B: Performing a neurovascular check every 2 hours is essential to monitor for any signs of impaired circulation or nerve damage.
D: Obtaining a prescription renewal every 72 hours ensures that the use of restraints is reviewed regularly and necessary adjustments can be made.
E: Implementing passive range-of-motion exercises helps prevent contractures and maintain joint mobility in immobile clients.
Summary:
C: Securing the restraint to the bedrail can pose a safety risk and restrict mobility, which is not recommended.
F and G: No choices provided.