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) Slide the patient into the new position: Sliding a patient when repositioning can create shear forces on the skin, which may contribute to skin damage. Shearing can occur when the skin sticks to the surface while the underlying tissues move, leading to increased risk of pressure ulcers. Therefore, sliding is not considered the most effective or safest way to reposition a patient at risk for skin impairment.

B) Place the patient in a 30-degree supine position: Placing the patient in a 30-degree supine position is a good method for reducing pressure on bony prominences and minimizing the risk of pressure injuries. However, while this position is helpful for preventing skin breakdown, it does not address the method of repositioning, which is what is being asked in this question.
C) Utilize a transfer device to lift the patient: Using a transfer device, such as a lift or slide sheet, to lift the patient is the best method for repositioning. This technique helps to reduce friction and shear forces on the skin, providing a safer and more effective way to move the patient without causing damage. Transfer devices also allow for a smoother repositioning, minimizing the risk of skin impairment.

D) Elevate the head of the bed 45 degrees: Elevating the head of the bed to 45 degrees can increase the risk of pressure injuries, especially if the patient is immobile and cannot relieve pressure themselves. This position can also contribute to shear forces as the patient slides downward. It may be appropriate in certain clinical situations, but it does not directly address the method of repositioning.

A. History of smoking B. Obesity C. Genetics D. History of hypertension

Correct Answer is C

Explanation

A) History of smoking: Smoking is a modifiable risk factor, meaning it can be reduced or eliminated through lifestyle changes. While smoking significantly increases the risk of stroke, it is not a nonmodifiable risk factor. Educating clients about the benefits of quitting smoking is important to reduce stroke risk.

B) Obesity: Obesity is also a modifiable risk factor. Lifestyle changes such as diet and exercise can help manage and reduce obesity, which in turn reduces the risk of stroke. While obesity increases the likelihood of stroke, it is not considered nonmodifiable.

C) Genetics: Genetics are a nonmodifiable risk factor. A family history of stroke or certain genetic predispositions can increase the risk of stroke. These genetic factors cannot be altered, which is why they should be included in the discussion about stroke risk factors.

D) History of hypertension: Hypertension, or high blood pressure, is a significant risk factor for stroke, but it is modifiable through medication, diet, and lifestyle changes. It is not a nonmodifiable risk factor. Managing blood pressure through appropriate treatment and lifestyle changes can reduce the risk of stroke.

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