A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

The provider should renew the prescription for restraints every 48 hr.

The nurse should pad the bony prominences.

The nurse should tie the restraints using a square knot.

The nurse should remove the restraints every 2 hr.

The provider's prescription should include the type of restraint to use.

Answer and Explanation

Correct Answer : B,D,E

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.

B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.

C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.

D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.

E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.

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Correct Answer is C

Explanation

A. Hydrogen peroxide is not recommended for cleaning surfaces contaminated with blood as it is not as effective as other agents and may not adequately disinfect surfaces.

B. Isopropyl alcohol can be effective for disinfecting surfaces contaminated with blood, but it is less effective against certain bloodborne pathogens like hepatitis B virus compared to chlorine bleach.

C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and is recommended by CDC guidelines for disinfecting against bloodborne pathogens.

D. Chlorhexidine is primarily used as a skin antiseptic and is not typically used for cleaning surfaces contaminated with blood.

A. Encourage client fluid intake of 2,500 mL daily. B. Moisturize dry skin areas on the client every other day. C. Place a dehumidifier in the client's room. D. Apply a donut ring pillow under the client's sacral area.

Correct Answer is A

Explanation

A. Adequate hydration helps maintain skin integrity and reduces the risk of pressure injuries by keeping the skin hydrated and resilient.

B. Moisturizing dry skin is important for overall skin health but may not directly prevent pressure injuries.

C. While maintaining a comfortable room environment is important for the client's overall well- being, a dehumidifier specifically may not directly prevent pressure injuries.

D. Donut ring pillows are not recommended for pressure injury prevention as they can actually increase pressure on vulnerable areas of the skin, leading to tissue damage.

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A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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