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A nurse is providing teaching to assistive personnel 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 hr.

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

Answer and Explanation

The Correct Answer is C

Restraints should be removed every two hours to assess skin integrity under the restraints and distal circulation

A. A square knot may be difficult to release in the case of an emergency

B. Restraints should be attached to movable parts of the bed to avoid injury during pulling.

D. Allow two fingerbreadths between the restraint and the wrist

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Correct Answer is C

Explanation

Referral to an occupational therapist is needed when clients experience difficulty with activities of daily living (ADLs) like bathing, grooming, eating and toileting. Bathing relates to personal hygiene whose difficulty may lead to other complications.

Incorrect- A. Walking is an important activity which may need occupational therapy but not as important as bathing

B and D. requires relaxation techniques, analgesics and nutritionist review respectively.

A. Notify the client's provider about the incident. B. Instruct the AP to discontinue the conversation. C. Complete an incident report about the breach of client confidentiality. D. Reassign the AP to other clients on the unit.

Correct Answer is B

Explanation

Instrucing them to discontinue the conversation immediately offers a solution instantly protecting the client's confidentiality.

While notifyin the provider and completing an incident report may be feasile, they may delay intervention leading to more harm.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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