A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?
Monitor the child's vital signs every 15 min.
Obtain a prescription for the restraints within 2 hr of initiating them.
Have the child perform range-of-motion exercises every 3 hr.
Ensure three fingers will fit between the child's wrist and the restraint.
The Correct Answer is A
a. This option is most appropriate in the context provided, as frequent monitoring is essential for a child in restraints to ensure their safety and well-being.
b. Obtain a prescription for the restraints within 2 hr of initiating them. - This is incorrect because the standard requirement is to obtain a prescription within 1 hour of initiating the restraints, not 2 hours.
c. While range-of-motion exercises are important, they are typically recommended every 2 hours to prevent complications like contractures.
d. The correct procedure is usually to ensure that two fingers can fit between the wrist and the restraint to ensure it's not too tight or too loose.
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Correct Answer is B
Explanation
A. Check the client's condition after the procedure. - This task should not be delegated to assistive personnel (AP) as it requires assessment skills that are within the nurse's scope of practice.
B. Assist the client to ambulate for the first time following the procedure. - This is a task that can be delegated to AP. Ambulation assistance is within the AP's scope of practice, provided the nurse has assessed the client's stability beforehand.
C. Witness the client's signature on the consent for the procedure. - This task must be performed by a nurse or another licensed healthcare provider, as it involves ensuring that the client has given informed consent.
D. Give the client atropine 30 min before the procedure. - Administering medication is within the nurse's scope of practice and should not be delegated to AP.
Correct Answer is A
No explanation
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