Question

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following should the nurse take?

a) pad the clients wrist before applying the restraints
b) evaluate the clients circulation every 8hr after application
c) remove the restraints every 4hr to evaluate the clients status
d) secure the restraint ties to the beds side rails

Answer 1

A nurse must pad the patient's wrists, frequently check circulation, and periodically remove wrist restraints for assessment and care, while ensuring the restraints are secured to the bed frame, not the side rails.

Step-by-step explanation:

When applying wrist restraints for a client on a medical-surgical unit, a nurse must adhere to several safety protocols to ensure the patient's well-being. First and foremost, the nurse should pad the client's wrist before applying the restraints to prevent skin injuries and enhance the client's comfort. It's critical that the nurse evaluates the client's circulation frequently to ensure there is no compromise, typically at a minimum every hour, rather than every 8 hours as suggested in the question. Lastly, the restraints should be removed periodically, usually every 2 hours, to allow for assessment of the patient's physical and psychological status and to perform necessary hygiene and care activities.

The nurse should never secure restraint ties to the bed's side rails, as this poses a significant safety risk. Instead, the ties should be secured to the bed frame to allow the rails to be lowered without affecting the restraints.