An 86-year-old resident in an extended care facility will not leave her room until her hair is combed, her lipstick is on, and she is well groomed.

The resident is sociable and completely independent, but it is lunchtime before she is ready to leave her room.
Which plan should a nurse make regarding breakfast for this client?

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

• Check the person at least every 15 minutes
• Remove restraints and meet basic needs at least every 2 hours
• Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.

The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.

Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.

Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.

Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.

Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.