A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Attach the restraints to the fixed portions of the frame of the client's bed.

Remove the client's restraints every 2 hr

Secure the client's restraints with a square knot.

Allow 1 fingerbreadth between the restraint and the client's wrists.

Answer and Explanation

The Correct Answer is D

A.   Restraints should not be attached to the bed frame. Instead, they should be secured to a movable part of the bed (such as side rails) to prevent injury. Attaching restraints to the bed frame can cause harm to the patient and limit their mobility.
B.   While it's essential to assess and reposition restraints regularly, removing them entirely every 2 hours is not recommended unless the patient's condition allows for it. Restraints should be removed and repositioned at least every 2 hours to assess skin integrity, circulation, and comfort. However, they should not be removed entirely unless necessary.
C.   Square knots are not recommended for restraining patients because they can be difficult to untie quickly in case of an emergency. Quick-release buckles or Velcro fasteners are safer options.
D.   Allowing 1 fingerbreadth between the restraint and the client's wrists ensures proper circulation and prevents excessive tightness. Properly fitting restraints prevent injury while maintaining patient safety.

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Correct Answer is D

Explanation

A. Total parenteral nutrition (TPN) solution bags typically need to be replaced more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the solution. However, the frequency of bag changes may vary depending on institutional protocols and specific patient needs.
B. Peripheral IV solution bags may be changed less frequently than every 96 hours, as long as the solution remains sterile and the integrity of the infusion system is maintained. However, the frequency of bag changes may vary based on institutional policies and patient-specific factors.
C. Total parenteral nutrition (TPN) IV tubing typically needs to be changed more frequently than every 48 hours to prevent bacterial contamination and ensure the integrity of the TPN solution. However, the frequency of tubing changes may vary depending on institutional protocols and patient-specific factors.
D. Changing peripheral IV primary tubing every 96 hours is a recommendation consistent with infection control guidelines and helps prevent contamination and bloodstream infections. This practice is cost- effective while ensuring patient safety.

A. Tell the client to leave her purse in a drawer of the bedside table. B. Offer to store the purse at the nurses' station. C. Offer to place the purse in the facility safe. D. Place the purse in the clothing bag with the client's other belongings.

Correct Answer is C

Explanation

A. Leaving the purse in a drawer of the bedside table is not a secure option. While it may seem like a convenient place, it does not provide adequate security and might still be vulnerable to theft or misplacement.
B. Although storing the purse at the nurses' station might seem like a safer option, it may not be the most secure method. Items stored at the nurses' station could still be at risk of being misplaced or stolen.
C. Offering to place the purse in the facility safe is the most secure and appropriate action. Facility safes are designed to provide secure storage for valuables and are monitored and managed by the facility to ensure safety. This option directly addresses the client’s concern about theft and provides a high level of security for their belongings.
D. Placing the purse in a clothing bag with the client’s other belongings does not provide additional security and is not an effective way to protect valuables. The clothing bag might not be adequately secured or monitored, making it a less reliable option for safeguarding the purse.

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A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

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