A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Remove one restraint at a time.
Tie the restraints to the side rail,
Secure restraints with a square knot
Remove the restraints every 3 hr
The Correct Answer is A
When using restraints for the safety of the client and others, it is important to follow proper procedures to ensure the client's well-being and minimize the risk of injury. Removing one restraint at a time allows for better control and assessment of the client's behavior and response. It also helps maintain the client's safety by ensuring that at least one limb is restrained during the process.
Restraints should never be tied to the side rail as it can cause serious harm or injury to the client. Restraints should be attached to an immobilization device specifically designed for that purpose, such as a bed frame or a designated restraint chair.
Restraints should be secured with a quick-release mechanism, such as a buckle or Velcro, that allows for quick and easy removal in case of emergency or the need for rapid intervention. Tying restraints with a square knot can delay the removal process and may compromise the client's safety.
Restraints should only be used when necessary and as prescribed by the healthcare provider. The frequency and duration of restraint use should be based on the client's condition and the specific order from the healthcare provider. It is not appropriate to remove restraints based solely on a time schedule without considering the client's individual needs and safety. Regular assessments should be conducted to determine if continued use of restraints is required or if alternative interventions can be implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When selecting a vein for IV therapy, it is important to consider several factors, including accessibility, integrity, and suitability of the vein. In this case, the client has undergone a right mastectomy, which means the right arm and hand on the affected side might be compromised due to surgery and potential lymphedema. Therefore, it is advisable to avoid using the veins on the affected side.
The cephalic vein in the left distal forearm is a suitable choice because it is on the opposite side of the mastectomy and provides accessibility for venipuncture. It is important to assess theintegrity and condition of the vein before insertion to ensure it can accommodate the IV catheter and maintain patency throughout the infusion.
Correct Answer is A
Explanation
This abbreviation is commonly used and recognized in healthcare to indicate subcutaneous administration of medication. It refers to the injection of medication into the fatty tissue layer just below the skin.
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