Ch. 4 - Safety

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 use of a safety monitoring device that alerts the nurse when the pt is getting out of bed would be ideal. Do not ask the family to ensure pt doesn't get out of bed because that's not their responsibility.

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 and reasoning for restraints to pt and family. 2. pad bony prominences. 3. apply restraints to pt's ankles with hook and loop fasteners. 4. ensure that two fingers can fit between skin and restraint. 5. place limbs in anatomical position. 6. secure restraints to bed via slip 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 need for fluids and toileting every 2 hours.

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

Document other measures attempted before the restraints were implemented. Rationale: Physician needs to reorder medical restraints every 24 hours. PPE and the actual application methods of the restraints do not need to be documented.

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 Rationale: Extremity restraint is designed to be short term and limit all movement. The mummy restraint, elbow restraint and vest restraints are all inappropriate for this situation

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 fluids. Rationale: Nurse must give opportunity for fluids, food, toilet every two hours. Nurse must also check skin integrity every two hours. As needed restraint orders are never ordered. If the restraints are removed and need to be placed again, a new prescription is needed.