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:
Pad bony prominences before applying a restraint.
Rationale:
✅ Pad bony prominences before applying a restraint
🟢 Protects fragile skin: Older adults in long-term care facilities often have thin, delicate skin that is prone to breakdown. Padding reduces direct pressure from the restraint against bony areas like the wrists, ankles, and elbows.
🟢 Prevents complications: Without padding, restraints can cause bruising, abrasions, or even skin tears. Over time, continuous pressure in these areas can result in pressure ulcers or impaired skin integrity.
🟢 Supports circulation: Padding helps reduce excessive pressure on blood vessels, which could otherwise compromise circulation and increase the risk of swelling or tissue injury.
🟢 Enhances comfort: Adding padding improves the client’s overall comfort, making the restraint less restrictive and more tolerable. This aligns with nursing’s ethical responsibility to minimize harm and preserve dignity.
🟢 Demonstrates best practice: By padding, nurses follow restraint safety guidelines that emphasize balancing client safety with comfort while reducing harm.
✅Ensure that 2 fingers can be placed between the restraint and the client
🔵 Prevents overly tight application: Restraints applied too tightly can cut off circulation, cause numbness, tingling, or nerve injury. The “two-finger rule” provides a standard for safe, effective restraint placement.
🔵 Promotes blood flow: Allowing space between the restraint and the skin ensures that blood can continue to circulate freely, preventing ischemia, edema, or permanent nerve damage.
🔵 Maintains effectiveness without risk: Restraints should be secure enough to prevent removal, but not so tight that they pose danger. The two-finger guideline achieves this balance.
🔵 Facilitates regular monitoring: Nurses can quickly check restraint fit during assessments to confirm the device is both effective and safe. This reinforces the practice of frequent monitoring required by safety standards.
🔵 Supports client dignity: Proper application shows respect for the client’s comfort while maintaining safety, an essential aspect of ethical nursing care.
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This question is from PN fundamentals 2023 (ATI) which contains 67 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 5