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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing pillows under the patient's hips and knees before turning is a common practice to maintain proper body alignment during the logrolling procedure. However, it is not the priority step. Placing the pillows is a part of the procedure but does not address the primary concern.
Choice B rationale:
Turning the patient only to the right side and never to the left is incorrect. Patients should be turned gently and carefully to either side, depending on the situation and the patient's condition. Restricting the movement to only one side can cause discomfort and potential injury to the patient.
Choice C rationale:
Raising the head of the bed to at least 30 degrees before turning is a good practice to prevent aspiration and facilitate breathing. However, it is not the priority step when logrolling a patient. Proper body alignment is crucial to prevent musculoskeletal injuries to the patient and the healthcare provider.
Choice D rationale:
The correct answer. Keeping the head, neck, back, hips, and legs in alignment with each other is the nursing priority when logrolling a patient. This technique ensures that the patient's spine is supported and prevents twisting or bending, reducing the risk of injury. Proper body mechanics are essential for both the patient's safety and the healthcare provider's safety during the procedure.
Correct Answer is D
No explanation
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.