Question

A primary health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 PM, the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action?

a) Client's distress
b) Restraints securely attached
c) Skin abrasions
d) Improved behavior

Answer 1

Skin abrasions indicate an unsafe action by the nurse who applied the restraints.

Step-by-step explanation:

When assessing the client with the restraints, the observation by the charge nurse that indicates the nurse who applied the restraints performed an unsafe action is skin abrasions. Skin abrasions suggest that the restraints may have been applied too tightly or improperly, causing harm to the client's skin. This could lead to further complications and potential infection.