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. This ensures regular evaluation of the need for continued restraint use.
B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.
D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.
E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.
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Related Questions
Correct Answer is C
Explanation
A. Set up the sterile field 7.6 cm (3 in) below waist level - While it's important to maintain a sterile field, the specific height mentioned is not a standard requirement.
B. Hold the bottle of sterile solution with the palm over the label while pouring - This is
incorrect because it increases the risk of contaminating the solution by touching the label.
C. Place the sterile items within 1 cm (0.4 in) of the edge of the sterile border - This is the correct action as it ensures that sterile items are easily accessible without reaching over the sterile field, minimizing the risk of contamination.
D. Place the lid of a bottle of sterile solution within the sterile field - Placing the lid inside the sterile field increases the risk of contamination, as the lid is not considered sterile.
Correct Answer is C
Explanation
A. Encouraging the parents to suppress their grief can be detrimental to their emotional well- being and may inhibit healthy grieving processes.
B. Avoiding discussing the funeral when the child is around may create confusion and anxiety for the child, who may sense that something significant is happening but is excluded from the discussion.
C. Including the child in the funeral service before visitors arrive allows the child to be part of the grieving process and provides an opportunity for closure and understanding of the sibling's death in a supportive environment.
D. While it is important for parents to understand how school-age children perceive death, this statement does not offer guidance on how to support the child during the grieving process.
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