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
◼️ Frequent skin assessments help prevent skin breakdown and pressure injuries caused by restraints.
◼️ Early identification of skin irritation or damage allows timely intervention.
◼️ This is a standard safety measure in restraint care.
⏹️Ensure that 2 fingers can be placed between the restraint and the client
◼️ This ensures the restraint is secured but not too tight, preventing impaired circulation or injury.
◼️ Proper fit allows for some movement and reduces risk of nerve damage.
◼️ Regular checks are needed to maintain this standard.
⏹️ Pad bony prominences before applying a restraint
◼️ Padding protects skin and tissues over bony areas from pressure and friction.
◼️ This measure decreases the risk of pressure ulcers.
◼️ It enhances client comfort and safety while restrained.
Want to practice more questions like this?
This question is from ATI PN Fundamentals~2023 Exam 5 which contains 53 questions.
More Questions from This Exam
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
Answer Choices:
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
Answer Choices:
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
Answer Choices:
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take.
Answer Choices:
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?
Answer Choices:
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 5