Quiz: Applying an 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.

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?

extremity restraint

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 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.

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?

Assess the client's need for fluids and toileting every 2 hours.

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.