Question

a nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. which of the following actions should the nurse include in the plan?

check that the restraint is tied to a fixed frame of the bed.

pad bony prominences on the wrist.

remove the restraint every 4 hr to allow movement.

tie the restraint with a knot that will tighten when pulled.

Explanation:

• For "Check that the restraint is tied to a fixed frame of the bed": Restraints should be tied to movable parts of the bed (like the side rail, not fixed frame) to allow bed movement, so this is incorrect.
• For "Pad bony prominences on the wrist": Padding bony prominences (like the wrist bones) under restraints is a standard nursing action to prevent pressure ulcers and injury, so this is correct.
• For "Remove the restraint every 4 hr to allow movement": Restraints should be removed at least every 2 hours (not 4) to assess and allow movement, so this is incorrect.
• For "Tie the restraint with a knot that will tighten when pulled": Restraints should have a quick - release knot (not one that tightens when pulled) for safety, so this is incorrect.

Answer:

B. Pad bony prominences on the wrist.