A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?<\/p>\n\n\n\n
A.
Retie the restraint straps with a slipknot.<\/p>\n\n\n\n
B.
Check that three fingers will fit beneath the restraints.<\/p>\n\n\n\n
C.
Retie the restraint straps to the side rails.<\/p>\n\n\n\n
D.
Remove the padding under the wrist restraints.<\/p>\n\n\n\n
The Correct answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n The correct answer is A. Retie the restraint straps with a slipknot.<\/strong><\/p>\n\n\n\n When using wrist restraints, it is essential to ensure that they are both effective and safe for the client. In this scenario, the assistive personnel (AP) has secured the straps with a double knot, which can make it difficult for the nurse to quickly release the restraints in an emergency. A slipknot, on the other hand, allows for rapid release while still securing the restraints adequately. This is crucial in maintaining client safety, particularly for a confused client who may be at risk of injury.<\/p>\n\n\n\n Additionally, it is important to assess the restraints to ensure they are not too tight. The standard practice is to allow enough space for at least two fingers to fit between the restraint and the client’s skin. This minimizes the risk of circulation impairment or skin breakdown. While option B suggests checking that three fingers fit beneath the restraints, it does not address the urgency of retying the straps appropriately.<\/p>\n\n\n\n Options C and D are inappropriate. Tying restraints to the side rails can pose a risk if the rails are lowered, potentially leading to the client being trapped or injured. Removing the padding (option D) undermines the purpose of using restraints safely, which is to prevent injury to the client’s skin from the restraints themselves.<\/p>\n\n\n\n In summary, the nurse should retie the restraint straps with a slipknot to ensure a balance between security and the ability to respond quickly if needed, while also maintaining safe practice standards regarding the fitting and application of restraints. This action aligns with the principles of safe and effective nursing care, prioritizing both the client’s safety and comfort.<\/p>\n","protected":false},"excerpt":{"rendered":" A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.Which of the following actions should the nurse take? A.Retie the restraint straps with a slipknot. B.Check that three […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-141567","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141567","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=141567"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141567\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=141567"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=141567"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=141567"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Explanation:<\/h3>\n\n\n\n