A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?

Anticipate removing the restraints every 4 hr.

Ensure four fingers fit under the restraints to prevent constriction.

Secure the restraints using a quick-release tie.

Secure the restraints to the lowest bar of the side rail.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C. Secure the restraints using a quick-release tie.

Choice A rationale: Anticipate removing the restraints every 4 hr. This is incorrect because restraints should be removed more frequently to assess the client's skin integrity, circulation, and overall need for continued restraint. Best practices typically suggest removing restraints every 2 hours for these checks.

Choice B rationale: Ensure four fingers fit under the restraints to prevent constriction. This is incorrect as well. The correct practice is to ensure that only two fingers can fit under the restraints. Allowing four fingers may lead to improper restraint, increasing the risk of injury or the restraint slipping off.

Choice C rationale: Secure the restraints using a quick-release tie. This is correct because quick-release ties are designed to allow rapid removal of restraints in case of emergency, ensuring the client's safety while also maintaining restraint effectiveness.

Choice D rationale: Secure the restraints to the lowest bar of the side rail. This is incorrect because restraints should never be secured to a movable part like the side rail, as it can cause injury if the rail is adjusted. Restraints should be secured to the bed frame, which is stable and stationary.

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Correct Answer is A

Explanation

A. Identifies viruses across the world. B. Establishes health objectives for Americans. C. Utilizes health data from the past 20 years. D. Monitors nonmodifiable risk factors.

Correct Answer is B

Explanation

Choice A rationale:

The statement "Identifies viruses across the world" is not an accurate description of the Healthy People 2030 framework. This framework focuses on health objectives and goals for Americans, not the identification of viruses. It is designed to improve the health and well-being of people in the United States, not to identify viruses globally.

Choice C rationale:

The statement "Utilizes health data from the past 20 years" is not a primary purpose of the Healthy People 2030 framework. While it may incorporate historical health data to inform its objectives, the framework's main goal is to set health objectives for the future, not exclusively based on past data. It aims to address current and future health needs and challenges.

Choice D rationale:

The statement "Monitors nonmodifiable risk factors" does not accurately describe the main focus of the Healthy People 2030 framework. While the framework may consider various health risk factors, it primarily concentrates on setting health objectives and goals to improve the health of Americans. The monitoring of nonmodifiable risk factors is not its central purpose.

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A newly licensed nurse is applying prescribed wrist restraints on a client.
Which of the following actions should the nurse take?