Safety - Restraints

The nurse is giving report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? 1. every 2 hrs 2. every 3 hrs 3. every 4 hrs 4. every 30 min

4. every 30 min (restraints should be checked every 30 min and removed every 2 hrs) NCLEX

QSEN

Quality and Safety Education for Nurses 6 QSEN competencies: 1. safety 2. patient-centered care 3. evidence-based practice 4. informatics 5. quality improvement 6. teamwork and collaboration

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) a. Check the patient's peripheral pulse in the restrained extremity b. Evaluate the patient's need for toileting c. Offer the patient fluids if appropriate d. Release both limbs at the same time to perform range of motion (ROM) e. Inspect the skin under each restraint

a. Check the patient's peripheral pulse in the restrained extremity b. Evaluate the patient's need for toileting c. Offer the patient fluids if appropriate e. Inspect the skin under each restraint Fundamentals ch 27

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails -safety device straps are secured to the bed frame and never to the side rails to avoid injury if the side rails are released NCLEX

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? a. Fasten the ties on the restraint to the side rails of the bed b. Tie the restraint with a quick-release knot c. Allow one finger's breadth between the restraint and the client's chest d. Place the restraint under the client's clothing

b. Tie the restraint with a quick-release knot ATI

A nurse is caring for a client following a total hip arthroplasty. The client is confused, moving his leg into positions that could dislocate the new hip joint, and he repeatedly attempts to get out of bed. After determining that restraint application is indicated, which of the following actions should the nurse take? (Select all that apply) a. secure the restraint to the frame of the bed b. get a prescription for restraints from the provider c. have a family member sign the consent for restraints d. use a square knot to secure the restraints to the bed e. ensure that only 1 finger can be inserted between the restraint and the client

a. secure the restraint to the frame of the bed b. get a prescription for restraints from the provider c. have a family member sign the consent for restraints -secure restraints to an immovable part of the bed -quick-release knot must be used to secure the restraint -the distance between the restraint and pt should be 2 finger widths ATI Leadership and Management

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. What is the correct order for applying a wrist restraint? a. Be sure that patient is comfortable with arm in anatomic alignment. b. Wrap wrist with soft part of restraint toward skin and secure snugly. c. Identify patient using two identifiers. d. Introduce self and ask patient about his feelings of being restrained. e. Assess condition of skin where restraint will be placed.

c, d, a, e, b 1. c. Identify patient using two identifiers. 2. d. Introduce self and ask patient about his feelings of being restrained. 3. a. Be sure that patient is comfortable with arm in anatomic alignment. 4. e. Assess condition of skin where restraint will be placed. 5. b. Wrap wrist with soft part of restraint toward skin and secure snugly. Fundamentals ch 27