Question

A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describe an accurate action to take when applying these restraints?

a. Apply restraints to the hands or wrists, never to the ankles
b. Ensure that two fingers can be inserted between the restraint and the client's extremity
c. Use a quick-release knot to tie the restraint to the side rail
d. Remove the restraint at least every four hours, or according to agency policy

Answer 1

Accurate actions when applying restraints include ensuring two fingers can fit between the restraint and extremity, not using quick-release knots on side rails, and removing the restraint per agency policy, usually every four hours.

Step-by-step explanation:

When applying restraints to a client who is confused and at risk of injury, it's important to follow specific guidelines to ensure the safety and well-being of the client. An accurate action to take includes ensuring that two fingers can be inserted between the restraint and the client's extremity. This is to prevent the restraints from being too tight, which could impede circulation or cause injury. Restraints should not be tied to the side rails with a quick-release knot as this could entail a risk of entrapment or injury if the rail is lowered. Instead, secure the restraint to the bed frame to eliminate this risk. Restraints should also be removed according to agency policy, which often suggests at least every four hours to provide necessary care, assess skin integrity, and offer range-of-motion exercises.