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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Provide educational material written at an eighth-grade reading level: This ensures that the educational material is accessible and understandable for clients, facilitating better comprehension and retention of information.
B. Turn on the television in the client's room: This is not conducive to effective teaching and may distract the client from the important information being provided.
C. Use technical language in the educational session: Using technical language can confuse clients and hinder their understanding. It is better to use plain language to ensure clarity.
D. Start with the most important information: While prioritizing information is important, the initial focus should be on assessing the client's understanding and tailoring the teaching to their specific needs before covering critical details.
Correct Answer is C
Explanation
A. Acute Pain: This represents the diagnostic label in the nursing diagnosis but does not include specific symptoms or evidence related to the client's condition.
B. Natural swelling: This is not relevant to the symptoms described in the scenario and does not represent the specific signs of the client's condition.
C. Guarding and restricted movement: This describes the specific observable signs and symptoms reported by the patient, which are part of the "Signs and Symptoms" component (S) in the PES format.
D. Related to incisional trauma: This part of the diagnosis describes the cause or contributing factor of the pain, which is the "Etiology" component, not the "Signs and Symptoms."
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