Practice Quiz

CRNE Canadian Registered Nurse

Category - Wellness

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A nurse is caring for Maria, an elderly client who is placed in hand restraints. To ensure safety and to prevent injuries, which of the following interventions is the most appropriate when caring for this client?
  1. Assess the neurovascular and circulatory status of the client every hour.
  2. Assess the skin integrity every 2 hours.
  3. Remove the restraint at least every 2 hours.
  4. Assess the skin integrity and remove the restraint every 2 hours.
Explanation
Answer: B - The nurse should remove the restraint at least every two hours. Removing the restraints allows the client to exercise her muscles, maintain good blood flow, and promote circulation. Skin integrity and neurovascular and circulatory status are assessed every 30 minutes. The nurse should continuously assess the client’s need for restraints.
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