A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
The provider should renew the prescription for restraints every 48 hr.
The nurse should pad the bony prominences.
The nurse should tie the restraints using a square knot.
The nurse should remove the restraints every 2 hr.
The provider's prescription should include the type of restraint to use.
Correct Answer : B,D,E
A. The provider should renew the prescription for restraints every 24 hours, not 48 hours.
B. Padding bony prominences helps prevent skin breakdown and pressure injuries.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in an emergency.
D. Removing the restraints every 2 hours allows for circulatory assessment, skin care, and range of motion exercises.
E. The provider's prescription should specify the type of restraint to ensure proper and appropriate use.
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Related Questions
Correct Answer is A
Explanation
A.
A. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.
B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.
C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.
D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.
Correct Answer is A
Explanation
A.
A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.
B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.
C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.
D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.
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