A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

The restraint is attached to the side rails of the bed.

The restraint the strap is tied into a knot.

The nurse can insert two fingers under the restraint.

The skin under the restraint is cool and has changed color.

Answer and Explanation

The Correct Answer is C

A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.

B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.

C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.

D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.

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Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

A. An assistive personnel weighs and bathes the newborn in an empty client room B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening C. The caregiver and newborn have matching hospital identification bracelets D. A hospital volunteer leaves the unit with the newborn to allow caregiver to rest

Correct Answer is D

Explanation

A. An assistive personnel weighs and bathes the newborn in an empty client room: While this may not be ideal practice depending on facility policy, it does not necessarily indicate a security threat unless the newborn is removed from secured areas without authorization.

B. Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: It is common for nurses to transport newborns for necessary procedures, provided proper identification protocols are followed. This situation does not automatically trigger a security alert.

C. The caregiver and newborn have matching hospital identification bracelets: Matching ID bracelets are part of the standard safety protocol to ensure correct infant identification and prevent abduction. This situation demonstrates proper security measures.

D. A hospital volunteer leaves the unit with the newborn to allow the caregiver to rest: Volunteers are not authorized to transport newborns outside of secured areas. This action represents a serious breach of security and requires the immediate initiation of a security alert to prevent potential abduction or harm.

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A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

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