Unformatted text preview: RN VATI Leadership X
a nurse is tria
A nurse is updating a client's plan of care to include the use of a wrist restraint. Which of the following interventions should the nurse include in
Provide skin care twice per shift.
The nurse should assess the client's skin integrity and provide skin care each time the restraints are removed.
Secure the restraint to the side rail of the bed.
the rail is lowered.
The nurse should not tie the restraint to the side rails or to the fixed frame of the bed. The client is at risk for injury if the restraint is secured to the side rail and
Release the restraint at least every 2 hr.
The nurse should plan to release the restraint at least every 2 hr. This allows the nurse the opportunity to assess the client's needs for nutrition and toileting as
well as assess the skin and provide range-of-motion exercises.
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- Fall '19
- Computer keys, client's plan