A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?

Apply ankle restraints but leave the wrists unrestrained.

Tie a double knot that is difficult to undo.

Tie a slip knot to the side rails of the bed.

Check on the patient frequently.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.

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Correct Answer is B

No explanation

A. The nurse is not responsible since the nurse was following the doctor's orders. B. Only the nurse was responsible since the nurse administered the medication. C. Both the nurse and the physician are responsible for the error. D. Only the physician is responsible since he or she ordered the drug.

Correct Answer is C

Explanation

Choice A rationale:

The nurse is not responsible since the nurse was following the doctor's orders. Rationale: While it is essential for nurses to follow physician orders, they also have a responsibility to assess the appropriateness and safety of those orders. If the nurse administers a medication that is clearly harmful or beyond the normal dosage, they have a duty to question the order and seek clarification from the physician. Administering a medication that is twice the normal dosage without questioning the order would be a breach of the nurse's responsibility.

Choice B rationale:

Only the nurse was responsible since the nurse administered the medication. Rationale: While the nurse did administer the medication, the ultimate responsibility lies with both the nurse and the physician. The nurse should have questioned the order if it appeared to be incorrect or unsafe. Nurses are advocates for their patients and have a duty to ensure the safety and well-being of those under their care.

Choice C rationale:

Both the nurse and the physician are responsible for the error. Rationale: This is the correct choice. Both the nurse and the physician share responsibility for the error. The nurse should have questioned the order, and the physician should have prescribed the correct dosage. Patient safety is a collaborative effort, and both healthcare providers are accountable for ensuring that the patient receives appropriate and safe care.

Choice D rationale:

Only the physician is responsible since he or she ordered the drug. Rationale: While the physician did order the drug, the nurse also has a responsibility to assess the order and question it if necessary. Nurses are trained to use their clinical judgment and critical thinking skills to ensure the safety of their patients. If the nurse administers a medication without questioning a clearly incorrect dosage, they share responsibility for the error.

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A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.Which action is appropriate for the nurse to conduct for a patient in restraints?

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A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?