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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults.

B. Malnutrition is characterized by a BMI below the healthy weight range and is typically associated with BMI values less than 18.5.

C. Overweight is characterized by a BMI between 25 and 29.9.

D. Obesity is characterized by a BMI of 30 or higher.

A. A client who has gastroenteritis and is lethargic and confused B. A client who has cystic fibrosis, has a thick, productive cough, and reports thirst C. A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic D. A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL

Correct Answer is A

Explanation

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

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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.)

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