A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?
Request a prescription renewal from the provider every 36 hr.
Make sure two fingers fit under the restraints.
Check the client's range of motion every 6 hr.
Secure the restraints with a square knot.
The Correct Answer is B
A. Restraint prescriptions typically need to be renewed at least every 24 hours, not every 36 hours, to comply with regulatory standards.
B. Ensuring that two fingers fit under the restraints is essential to confirm that they are not too tight, allowing for circulation and comfort while still securing the client.
C. Checking the client's range of motion should occur more frequently than every 6 hours; ideally, it should be assessed more regularly to prevent complications.
D. Restraints should be secured using a quick-release knot, not a square knot, to ensure they can be removed easily in an emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Explanation
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Explanation
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