Practice Quiz

CRNE Canadian Registered Nurse

Category - Wellness

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A nurse obtains an order from a physician to restrain an Anna, an elderly client. Anna has attempted to remove a feeding tube three times in the past 24 hours. A jacket restraint is ordered. Which of the following actions by the nurse demonstrates proper application of the restraint to the client?
  1. The device is secured to the side rails.
  2. The jacket is restrained such that one finger can easily slide between the client’s skin and the restraint.
  3. The nurse ensures that the restraint traps tighten when the force is applied against them.
  4. The nurse uses a half-bow knot to secure the restraint.
Explanation
Answer: D - The nurse should use a half-bow knot. This intervention allows quick release of the knot. The device must be secured to the bedframe or chair. Securing the device to the side rails may cause an injury when the side rail is released. The nurse should be able to slide two fingers between the client’s skin and the restraint to ensure that it is not applied too tightly.
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