Safe, Effective Care Environment
31. A client is very agitated and needs to have soft restraints applied. To ensure the safety of the client, the nurse should:
Safe, Effective Care Environment
31. A client is very agitated and needs to have soft restraints applied. To ensure the safety of the client, the nurse should:
. Tie restraints to the side rails.
. Keep the head of the bed elevated 30 degrees to keep tension on the restraints.
. Inspect the client's skin under the restraints every 2 hours.
. Turn on the lights in the room to see the client.
Test-Taking Tip
Choose an option that directly relates to the client; side rails, head of bed, or lights indirectly affect the client.
Content Area: Adult Health, Integumentary; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Use of Restraints/Safety Devices
Safe, Effective Care Environment
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Answer 1 is incorrect because restraints are never tied to the side rails. This increases the chance of injury. Answer 2 is incorrect because ideally there should be no tension on the restraints. Answer 3 is correct because the tightness of the restraints and the effects on client's skin must be frequently assessed. Answer 4 is incorrect because usually the lights should be dimmed to decrease stimuli when a person is agitated.