Which of the following is essential when restraints are applied to a client?

Use a square knot.

Assess the extremity for circulation and neurological integrity every 2 hours.

Secure the restraint to the side rail.

Assess restraints and skin integrity every 12 hours.

Answer and Explanation

The Correct Answer is B

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.

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Correct Answer is C

Explanation

A. Grandparents: While grandparents can provide useful information, the primary and most accurate data source for a toddler's immediate care and developmental history would typically be the parents, who are the primary caregivers.
B. Admitting provider: The admitting provider offers valuable medical information, but the best source of data regarding the child’s current condition and history would come from those who are closest to the child and involved in their daily care.
C. Parents: Parents are the most reliable source for accurate and up-to-date information about their child’s health, developmental history, and current condition. They are directly involved in the child's daily life and care.
D. Medical record: While the medical record contains important historical data, the most current and relevant information about the toddler’s condition and immediate needs should be obtained from the parents.

A. Placing a high risk for falls armband on the patient B. Checking on the patient once a shift C. Keep the bed in the lowest position D. Placing all four side rails in the "up" position E. Maintain call light within reach of the patient

Correct Answer is ["A","C","E"]

Explanation

A. Placing a high risk for falls armband on the patient: An armband alerts all healthcare providers to the patient's fall risk, helping to ensure appropriate precautions are taken.
B. Checking on the patient once a shift: This is not sufficient; patients on fall precautions should be checked more frequently, such as every hour or according to the facility's protocol, to ensure their safety.
C. Keep the bed in the lowest position: Keeping the bed at its lowest position reduces the risk of injury from falls and helps ensure the patient can easily get in and out of bed.
D. Placing all four side rails in the "up" position: Using all four side rails is not recommended as it can increase the risk of entrapment and may not be effective in preventing falls. Side rails should be used appropriately and in accordance with safety protocols.
E. Maintain call light within reach of the patient: Ensuring the call light is within reach helps the patient call for assistance if needed, which can help prevent falls.

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Which of the following is essential when restraints are applied to a client?

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Naxlex Comprehensive Predictor Exams

The nurse working in the ER is admitting a toddler to the orthopedic unit. The parents and grandparents are at bedside. What should the nurse use as the best source of data for this client?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","E"]

Explanation

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