Difficulty: Medium
Average Score: 81%
Simulated
A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
Correct answer
B,D,E
Rationale
Correct Answer: B,D,E
Rationale:
B: The nurse should pad the bony prominences to prevent skin breakdown and pressure injuries while the client is restrained.
D: The nurse should remove the restraints every 2 hours to assess skin integrity, circulation, and provide the client with a break from the restraint.
E: The provider's prescription should include the type of restraint to use to ensure that the appropriate restraint method is selected based on the client's needs and safety.
Incorrect Choices:
A: The provider should renew the prescription for restraints every 48 hours is incorrect as restraints should be reviewed at least every 24 hours.
C: The nurse should tie the restraints using a square knot is incorrect as restraints should be tied using quick-release knots for easy removal in case of emergency.
Summary:
The correct choices emphasize the importance of client safety, skin integrity, and proper documentation in the use of restraints, while the incorrect choices focus on incorrect time intervals for prescription
Rationale:
B: The nurse should pad the bony prominences to prevent skin breakdown and pressure injuries while the client is restrained.
D: The nurse should remove the restraints every 2 hours to assess skin integrity, circulation, and provide the client with a break from the restraint.
E: The provider's prescription should include the type of restraint to use to ensure that the appropriate restraint method is selected based on the client's needs and safety.
Incorrect Choices:
A: The provider should renew the prescription for restraints every 48 hours is incorrect as restraints should be reviewed at least every 24 hours.
C: The nurse should tie the restraints using a square knot is incorrect as restraints should be tied using quick-release knots for easy removal in case of emergency.
Summary:
The correct choices emphasize the importance of client safety, skin integrity, and proper documentation in the use of restraints, while the incorrect choices focus on incorrect time intervals for prescription