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 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.

A. Use a dosimeter to measure the level of radiation in the area before intervening, B. Wait until the type of equipment needed is known. C. Choose the highest level of protection equipment available. D. Decontaminate victims before intervening.

Correct Answer is C

Explanation

A) Use a dosimeter to measure the level of radiation in the area before intervening:
While a dosimeter can be useful for measuring radiation levels, it is not the immediate priority in a mass casualty incident. The nurse's first concern should be to ensure personal safety by choosing the most appropriate PPE based on the unknown nature of the hazard. Delaying action to measure radiation might delay critical intervention for victims.

B) Wait until the type of equipment needed is known:
Waiting to determine the exact type of personal protective equipment (PPE) is not a safe strategy in a mass casualty incident. The nurse should be prepared to act quickly to provide care, and waiting to ascertain PPE could jeopardize both the nurse's safety and the safety of the victims. Immediate action, even with the highest available PPE, is more important than waiting for full details.

C) Choose the highest level of protection equipment available:
In a mass casualty incident where the type of hazard is unknown, choosing the highest level of protection ensures the nurse is safeguarded against a broad range of potential risks, such as chemical, biological, or radiological exposure. This action prioritizes safety while providing the flexibility to intervene without delay.

D) Decontaminate victims before intervening:
While decontamination is crucial in a hazardous incident, the nurse's first responsibility is their own safety. Without the proper PPE, the nurse could become contaminated. After donning the appropriate protective equipment, the nurse can then assist with decontaminating victims if necessary. Decontaminating victims should not be the first step before ensuring the nurse is properly protected.

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