A nurse is teaching a newly licensed nurse about the use of restraints for adult clients. Which of the following information should the nurse include in the teaching?

The nurse should document observation of the client every 15 min.

The provider should assess the client 48 hr after the restraint is applied.

The prescription for a restraint should be renewed by the provider 6 hr after application.

The nurse should assist the client with range-of-motion exercises every 12 hr after restraint application.

Answer and Explanation

The Correct Answer is A

Choice A reason: Documenting observation every 15 min is correct. Frequent monitoring ensures client safety, assesses circulation, skin integrity, and psychological well-being, and prevents complications such as injury or restricted blood flow.

Choice B reason: The provider should assess the client much sooner than 48 hr. Restraint use requires frequent reassessment, typically within 24 hr, to determine ongoing necessity. Waiting 48 hr is unsafe.

Choice C reason: The prescription for a restraint should be renewed every 24 hr, not 6 hr. Restraints require daily provider review to ensure they remain necessary and appropriate.

Choice D reason: Range-of-motion exercises should be performed every 2 hr, not every 12 hr. Frequent ROM prevents contractures, maintains circulation, and reduces complications from immobility.

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Correct Answer is C

Explanation

Choice A reason: Maintaining the foot above the level of the head is excessive and not recommended. Elevation should be above the level of the heart to reduce swelling, not above the head.

Choice B reason: Numbness and tingling are not expected after a sprain. These symptoms may indicate neurovascular compromise and should be reported immediately.

Choice C reason: Applying ice for 20 min intervals is correct. Ice reduces swelling, inflammation, and pain by causing vasoconstriction. The 20-min interval prevents tissue damage from prolonged cold exposure.

Choice D reason: Performing range of motion exercises immediately after injury is inappropriate. Rest is required during the acute phase to prevent further damage. ROM exercises are introduced later during rehabilitation.

A. Encourage the client to ambulate in the hallway 1 hr before bedtime. B. Tell the client to avoid drinking fluids 1 hr before bedtime. C. Schedule routine care tasks during hours when the client is awake. D. Advise the client to leave the television in the room on when trying to fall asleep.

Correct Answer is C

Explanation

Choice A reason: Ambulating in the hallway 1 hour before bedtime may increase stimulation and alertness, making it harder for the client to fall asleep. While exercise is beneficial earlier in the day, late evening activity can interfere with sleep onset.

Choice B reason: Avoiding fluids before bedtime helps reduce nocturia but does not directly address difficulty falling asleep. This intervention is more appropriate for clients with frequent nighttime urination rather than insomnia.

Choice C reason: Scheduling routine care tasks during hours when the client is awake is the correct answer because it minimizes nighttime disturbances. By aligning care with the client’s natural wakefulness, the nurse promotes uninterrupted rest and supports healthy sleep hygiene. This intervention directly addresses difficulty falling asleep by reducing external interruptions.

Choice D reason: Leaving the television on at night introduces light and noise, both of which disrupt melatonin secretion and sleep quality. Television use before bed is linked to delayed sleep onset and poor sleep efficiency.

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A nurse is teaching a newly licensed nurse about the use of restraints for adult clients. Which of the following information should the nurse include in the teaching?

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