A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Remove one restraint at a time.

Tie the restraints to the side rail,

Secure restraints with a square knot

Remove the restraints every 3 hr

Answer and Explanation

The Correct Answer is A

When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.

Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.

Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.

Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.

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Correct Answer is C

Explanation

The nurse should assess the pulses in the extremities to ensure that circulation is not compromised by the restraints.

Once the nurse has confirmed that the peripheral pulses are intact, they should assess the client's skin integrity. Prolonged or improperly applied restraints can cause pressure injuries or skin breakdown, so it is important to check for any signs of skin damage.

After assessing peripheral pulses and skin integrity, the nurse should evaluate the client's comfort level. The nurse should address any discomfort or pain caused by the restraints and ensure that the client's physical and emotional needs are met.

While elimination needs are important, they may not pose an immediate threat to the client's safety compared to compromised circulation or skin integrity. Once the more urgent assessments have been completed, the nurse should address the client's elimination needs.

A. Secure the tracheostomy ties to allow one finger to fit snugly underneath. B. Use a cotton tip applicator to clean inside the inner cannula. C. Soak the outer cannula in warm, soapy tap water. D. Cleanse the skin around the stoma with normal saline

Correct Answer is A

Explanation

The tracheostomy ties should be secure enough to keep the tracheostomy tube in place but loose enough to allow for proper circulation and prevent skin breakdown. Allowing one finger to fit snugly underneath ensures that the ties are not too tight, which can compromise blood flow

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A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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