NUR 311L Skills Lab - Extremity Restraint
The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse? Use a safety monitoring device. Check the client every 30 minutes. Restrain the client. Ask a family member to sit with the client.
Use a safety monitoring device Rationale: A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.
The nurse is preparing to apply prescribed extremity restraints to a client's ankles. Place in order the steps of the procedure the nurse should perform. Use all options. Explain rationale for use to the client and family. Position limbs in normal anatomic position. Pad bony prominences. Ensure that two fingers fit between the restraint and the client's skin. Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. Secure restraints to the bed frame with quick-release knots. Clear Response
1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.
The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate? Secure the wrist restraints to the side rail. Assess the client's need for fluids and toileting every 2 hours. Delegate evaluations of the restraints at 2-hour intervals to unlicensed assistive personnel (UAP). Perform the client's activities of daily living (ADLs).
Assess the client's need for fluids and toileting every 2 hours. Rationale: Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.
The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? mummy restraint waist restraint elbow restraint extremity restraint
Extremity restraint Rationale: The extremity restraint is appropriate during an accidental removal of therapeutic devices, because it provides short-term restraint designed to control all movement. The vest restraint, mummy restraint, and elbow restraint are not appropriate in this situation.
The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform? Ensure an as needed restraint prescription is in place and signed. Instruct the client that improved behavior results in restraint removal. Reassess cognitive status and the need to continue the restraints. Perform a circulation check and offer toileting and hydration.
Perform a circulation check and offer toileting and hydration. Rationale: Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.
The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? a detailed description of the restraint application process a verbal prescription for the restraints, renewed every 48 hours the type of personal protective equipment used by the nurse during restraint application the alternative measures attempted before applying the restraints
The alternative measures attempted before applying the restraints. Rationale: Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.
