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

Secure the client's restraints with a square knot

Attach the restraints to the fixed portion of the frame of the client's bed

Remove the client's restraints every 2 hours

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

Answer and Explanation

The Correct Answer is B

A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.

B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.

C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.

D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.

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Correct Answer is C

Explanation

Choice A reason: Demonstrating use of the pump during medication administration is not the priority action by the charge nurse. This would not ensure that all staff nurses are competent and confident in using the new pump. It would also interrupt the workflow and patient care.

Choice B reason: Pairing an inexperienced nurse with an experienced nurse is not the priority action by the charge nurse. This would not address the knowledge gap of the staff nurses who are not paired. It would also create a dependency on the experienced nurse and a potential risk for errors.

Choice C reason: Planning an in-service education program on the unit is the priority action by the charge nurse. This would provide the staff nurses with the opportunity to learn about the new pump, its features, functions, and troubleshooting. It would also allow the charge nurse to assess the staff nurses' learning needs and evaluate their competency.

Choice D reason: Contacting the manufacturer of the pump for assistance is not the priority action by the charge nurse. This would not address the immediate needs of the staff nurses who are using the new pump. It would also depend on the availability and responsiveness of the manufacturer.

A. Document the concern in the nurse's notes B. Request help from the personnel on the unit C. Contact the nurse manager to discuss the situation D. Refuse to accept the assignment

Correct Answer is C

Explanation

Choice A reason: Documenting the concern in the nurse's notes is not an appropriate action. The nurse's notes are for recording the client's condition and the care provided, not for expressing the nurse's personal issues. This action does not address the problem or ensure the safety of the clients.

Choice B reason: Requesting help from the personnel on the unit is a good action, but not the best one. The nurse should seek assistance and guidance from experienced staff members, but they should also communicate their concern to the nurse manager, who is responsible for making appropriate assignments and providing support and resources.

Choice C reason: Contacting the nurse manager to discuss the situation is the best action. The nurse manager can evaluate the nurse's competency and experience level, and adjust the assignment accordingly. The nurse manager can also provide feedback, education, and supervision to the nurse to enhance their skills and confidence.

Choice D reason: Refusing to accept the assignment is not an appropriate action. The nurse has a professional and ethical obligation to provide care to the clients, unless there is a clear conflict of interest or violation of standards. The nurse should not abandon the clients or the unit without a valid reason.

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A nurse is providing teaching to an assistive personnel (AP) 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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