Chapter 4 safety

the nurse is in a critical care unit caring for a child who is restrained with elbow restraints during a procedure. which interventions should take priority?

assess the circulation to the clients fingers and hands

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 the most appropriate?

assess the clients need for fluids and toileting every 2hours

The nurse is applying a waist restraint on a patient. What is a recommended guideline for this procedure? a. Choose the right size and most restrictive type. b. Assist the patient to a lying position. c. Place fist between vest and patient to ensure breathing. d. Place restraint on the patient under gown with ties in back

c

a nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. which action should the nurse recommend the client?

consult your health care provider about beginning an exercise program

the nurse considers applying restraints to an agitated client. which action does the nurse take?

dim the lights and speak softly about something the client enjoys

the nurse is assigned a client for whom an elbow restraint is prescribed. which general principles of correct placement of the elbow restraints will the nurse follow?

ensure the restraint is the correct size for the client. confirm the restraint does not extend below the wrist or place pressure on the axilla. pad the bony prominences.

a nurse is implementing measures as alternatives to using restraints. when implementing the clients plan of care , the nurse would anticipate the need to check on thee client in which frequency?

every 1 to 2 hours

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. how often should the nurse assess this client?

every 60 minutes

the nurse is preparing to apply prescribed extremity restrains to the clients ankles. place in order the steps of the procedures the nurse should perform.

explain the rationale for use to the client and family. pad bony prominences. wrap the restraints around the clients ankle and secure it with hook and loop fastener straps. ensure that 2 fingers fit between the restraints and thee clients skin. postion limbs in normal anatomical postion. secure restraints to the bed frame with quick release knots.

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 adults movement during the procedure

extremity restraint

a nurse is caring for a client who is wearing a waist restraint. which intervention by the nurse would be most appropriate to ensure that the clients breathing is not restricted?

insert fist between the restraint and the client

after applying a restraint to a client, the nurse is required to stay with the client while it is in use. which type of restraint has the nruse applied?

mummy restraint

the nurse is caring for a hysterical child who requires assessment of a dog bite neat the eye. the parent is in emotional state that is not appropriate for helping to immobilize the child. the nurse should implement which restraints to best enable to health care provider to examine the clients injury

mummy restraint

the nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. what should the nurse do immediately before applying the waist restraint?

pad the bony prominences

the nurse applied restraints to a client 2 hours ago for aggressive actions. what action does the nurse perform?

perform a circulation check and offer toileting and hydration

the nurse has finished discussion with an older adult client about dangers in the home. the nurse recognizes that the instruction was effective when the client identifies which common risks in the home?

polypharmacy, clutter, extension cords

a nurse is preparing an inservice program for a small group of staff nurses about ways to minimize restraint use on the unit. the nurse plans to address the risk associated with physical restraint use. which risk would the nurse include?

pressure injuries, contractures, delirium, falls

the nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. the adult child asks what they can do to keep their parent safe. what are the best instructions by the nurse

provide frequent reorientation, increase the patients social interactions, ensure the patient engages in regular exercise

the nurse is caring for an older adult for whom the health care provider has prescribed an elbow restraint. the elbow restraint should not impede circulation. which pulse will the nurse assess to decide if circulation is compromised?

radial

the nurse is caring for a middle aged adult who has been perscribed elbow restraints. the nurse observes that when the restraints are removed, the client cries and reports pain in the elbow. what is the best action by the nurse?

remove the restraints more frequently and perform range of motion.

the nurse is caring for an infant for whom the health care provider has prescribed a mummy restraint. the infants parent asks the nurse what will bee used to implement the mummy restraint on the infant. what is the best response by the nurse?

sheet or blanket

the nurse is caring for a client who has been prescribed extremity restraints. which action must be documented by the nurse.

the alternative measures attempted before applying the restraints

the nurse cares for a client wearing a waist restraint. which client action causes the nurse to change restraint types?

the client continually tries to move from head of th bed towards the foot of the bed

a toddler is to undergo a procedure for which the child needs to be restrained with a mummy restraint. the procedure is expected to take about 10 minutes. which approach might the nurse suggest as an alternative to using a mummy restraint ?

therapeutic holding

Is the following statement true or false? If a patient falls, the nurse must document the fall and complete a safety event form.

true

the nurse is preparing to administer a waist restraint to a client in a wheelchair. which method of securing the restraint is appropriate?

typing the restraint behind the chair

which recommendations should be included in a teaching plan for preventing falls in the home? select all that apply.

use a night light keep electrical and telephone cords against the wall and out of walkways avoid climbing on a chair or table to reach items that are too high remove clutter from walkways

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

the nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. a family member asks if the client will continue to wear the waist restraint. what is the best response by the nurse?

"the health care provider will see the client and assess whether the restraint prescription should be renewed"

the nurse is caring for a 2 year old for whom elbow restraints have ben prescribed. the nurse should remove the restrains and assess thee child every how many hours ___?

1

A nurse is placing restraints on an elderly patient who is at risk for falls. Which is NOT a recommended guideline in this process? A. Make sure there is an order from the physician. B. Do not involve the family in the process. C. Assess the patient for skin integrity. D. Make sure the benefits outweigh the risks.

B