A newly licensed nurse applying prescribed wrist restraints on client. Which of the following actions should the nurse take?

Ensure four fingers fit under the restraints to prevent constriction.

Secure the restraints to the lowest bar of the side rail.

Secure the restraints using a quick-release tie.

Anticipate removing the restraints every 4 hr.

Answer and Explanation

The Correct Answer is C

A) Ensure four fingers fit under the restraints to prevent constriction: While it is important to ensure that restraints are not too tight, the general recommendation is to allow enough room for two fingers, not four. The primary goal is to prevent impaired circulation and nerve damage while also ensuring that the restraint is secure enough to prevent the patient from causing harm to themselves or others. Four fingers may be too loose and could lead to unnecessary movement.

B) Secure the restraints to the lowest bar of the side rail: Restraints should never be secured to a side rail, as the side rails may move and cause the restraint to become tight, which could lead to injury. Restraints should be tied to a fixed part of the bed frame to prevent them from becoming loose or causing undue pressure. Securing to side rails can increase the risk of harm.

C) Secure the restraints using a quick-release tie: This is the correct action. The nurse should always use a quick-release tie to ensure that the restraints can be removed immediately if needed. Quick-release ties allow for rapid removal in case of emergency, reducing the risk of injury or distress to the patient. This ensures safety while still maintaining control over the restraint application.

D) Anticipate removing the restraints every 4 hr: While restraints should be removed periodically to check the skin, circulation, and comfort of the patient, the time frame for removal varies depending on the patient's condition and the facility's protocol. Restraints should be removed more frequently than every 4 hours, if possible, to ensure the patient’s safety and comfort. The nurse should follow the facility's specific protocol for restraint monitoring and removal.

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Correct Answer is C

Explanation

A) The client should first move the strong leg, then the weak one:
This instruction is not appropriate for cane use. When using a cane, the client should move the cane forward first, followed by the weak leg, and then the strong leg. This ensures proper support and balance while ambulating. Moving the strong leg first could cause instability and increase the risk of falls.

B) When the client moves, he should move the cane forward first:
This statement is partly correct, but it's only one part of the proper technique for cane use. The cane should be moved forward first, but then the weak leg should follow, and the strong leg should move last. This sequence helps the client maintain balance while using the cane.

C) The client should hold the cane on the weak side of his body:
This is the correct instruction. The cane should be held on the weak side (the side with the injury or decreased strength) to provide support and maintain balance while ambulating. Holding the cane on the weak side helps to transfer weight from the weak leg to the cane, improving stability and mobility.

D) The grip should be level with the client's wrist:
This statement is partially correct but lacks clarity. The cane's grip should be level with the client's wrist when standing upright, which ensures that the client can hold the cane with a slightly bent elbow, promoting better posture and more effective use of the device. However, it is essential to make sure the cane height is adjusted to the individual's specific needs, as the wrist level may not always be ideal for every client.

A. Provide support by holding the client’s arm. B. Assume narrow base of support. C. Lean the client toward the wall. D. Lower the lent to the floor.

Correct Answer is D

Explanation

A. Provide support by holding the client’s arm:
While holding the client's arm may seem like a way to prevent the fall, it can actually increase the risk of injury, as the nurse might not be able to support the client’s full weight and could cause additional strain or injury. In the event of a fall, it is safer to focus on guiding the client gently to the floor.

B. Assume a narrow base of support:
Assuming a narrow base of support could make the nurse more vulnerable to losing balance as well. A broader base of support, such as standing with feet shoulder-width apart, provides better stability, but this action does not directly address the client’s fall.

C. Lean the client toward the wall:
Leaning the client toward the wall may be helpful in some situations but does not directly prevent a fall. It may not be safe or feasible depending on the environment, and leaning the client toward a wall might cause further harm if not executed carefully.

D. Lower the client to the floor:
When a client begins to fall, the priority is to prevent injury. The nurse should gently lower the client to the floor while maintaining control, guiding the fall as much as possible to minimize injury. This approach ensures the client is not at risk of further harm and that the nurse can then assess the client for injuries.

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