When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?
Tie the restraints to the side rail.
Remove the restraints every 3 hr.
Remove one restraint at a time.
Secure restraints with a square knot.
The Correct Answer is C
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
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Related Questions
Correct Answer is D
Explanation
This is important to prevent urine from flowing back into the bladder, which can cause infection 1.
Choice A is incorrect because the catheter should be secured to the outer side of the thigh, not taped to the lower abdomen 2.
Choice B is incorrect because attaching the drainage bag to the side rails of the bed can cause it to be above the level of the bladder.
Choice C is incorrect because it is important to empty the drainage bag regularly, not just when it is three-quarters full.
Correct Answer is D
Explanation
This is because before providing the client with information about insulin self-administration and other resources, it is important to first determine whether the client can afford the insulin administration supplies.
This will help to ensure that the client has access to the necessary supplies for managing their diabetes mellitus.
Choice A is wrong because making a copy of the medication reconciliation form for the client is not the first action that should be taken.
While it is important to provide the client with a copy of their medication reconciliation form, this should be done after determining whether the client can afford the insulin administration supplies.
Choice B is wrong because obtaining printed information about insulin self-administration is not the first action that should be taken.
While it is important to provide the client with information about insulin self-administration, this should be done after determining whether the client can afford the insulin administration supplies.
Choice C is wrong because providing the client with the contact number for a diabetes education specialist is not the first action that should be taken.
While it is important to provide the client with resources for diabetes education, this should be done after determining whether the client can afford insulin administration supplies.
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