A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?

Retie the restraint straps with a slipknot.

Check that three fingers will fit beneath the restraints.

Retie the restraint straps to the side rails.

Remove the padding under the wrist restraints.

Answer and Explanation

The Correct Answer is A

The correct answer is choice a. Retie the restraint straps with a slipknot.

Choice A rationale:

The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.

Choice B rationale:

It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.

Choice C rationale:

Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.

Choice D rationale:

The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.

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Correct Answer is A

Explanation

Choice A rationale:

"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.

Choice B rationale:

"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.

Choice C rationale:

"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.

Choice D rationale:

"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .

A. "I will keep my walker at the end of my bed.". B. "I will keep the fluorescent ceiling light on in my room at night.". C. "I will place an area rug at the entry of my bathroom.". D. "I will place a bath seat in my shower to use when I bathe.". .

Correct Answer is B

Explanation

Choice A rationale:

Use a fire extinguisher on the outlet. Rationale: Using a fire extinguisher directly on an electrical outlet is dangerous and can lead to electrical shock. It is not the appropriate action to take in this situation. The nurse should prioritize safety and avoid actions that could cause harm to themselves or others.

Choice B rationale:

Activate the fire alarm. Rationale: This is the correct action. Activating the fire alarm alerts others in the facility, allowing for a swift response from the fire department and evacuation procedures to be initiated. Ensuring that everyone is aware of the emergency is essential for a coordinated and safe evacuation.

Choice C rationale:

Move any clients to safety. Rationale: While moving clients to safety is important, it is not the nurse's first priority in this scenario. Activating the fire alarm should come first to ensure a quick response from emergency services and to alert all staff and patients about the fire. Once the alarm is activated, moving clients to safety can be the next appropriate step.

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A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

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A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?