Practice Question
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Answer Choices:
Correct Answer:
Observe the client's skin integrity every 2 hr.
Rationale:
Observe the client's skin integrity every 2 hr.
🟠 The nurse must check skin integrity at least every 2 hours to prevent pressure injuries or compromised circulation caused by restraints.
🟠 Regular monitoring also includes checking for neurovascular status and documenting the client’s condition.
🟠 This is part of responsible restraint use and patient safety protocol.
Ensure that 2 fingers can be placed between the restraint and the client.
🟠 This standard ensures that the restraint is not too tight, allowing for proper circulation and comfort.
🟠 Tight restraints can cause skin breakdown or nerve damage, while loose restraints may be ineffective.
🟠 The two-finger rule is a universal guideline for safe restraint application.
Pad bony prominences before applying a restraint.
🟠 Padding protects vulnerable areas from friction, pressure, and skin breakdown, especially in immobile or elderly clients.
🟠 Elbows, wrists, and ankles should be padded if restraints are used on these areas.
🟠 Preventive measures are essential to reduce complications of restraint use.
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This question is from ATI PN Fundamentals ~2023 Exam II which contains 54 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 5