The nurse completes yearly training regarding the use of restraints. Which situation should the nurse categorize as a restraint?

Question

1. A safety belt applied across the client's waist when sitting in a geri chair with a quick release button demonstrated to the client
2. The use of the top side rail to provide something for the client to hold on to when getting out of bed
3. A safety belt around the infant when placing the child in a swing
4. The use of all four side rails on the bed after administering preoperative sedation

Answer 1

4
Rationale 1: The safety belt applied to the adult is not a restraint, because the client is shown how to open the belt if she wishes to remove it.
Rationale 2: Raising one side rail for support is not restraining the client because she can still get out of bed.
Rationale 3: A safety belt applied to an infant seat is not a restraint; it does not limit the child's movement, because the infant could not voluntarily get out of the chair without injury.
Rationale 4: When the nurse pulls all four side rails up on the client's bed, he is restraining the client unless he obtains the client's permission prior to administering the preoperative sedation.
Global Rationale: When the nurse pulls all four side rails up on the client's bed, he is restraining the client unless he obtains the client's permission prior to administering the preoperative sedation. Raising one side rail for support is not restraining the client because she can still get out of bed.The safety belt applied to the adult is not a restraint, because the client is shown how to open the belt if she wishes to remove it. A safety belt applied to an infant seat is not a restraint; it does not limit the child's movement, because the infant could not voluntarily get out of the chair without injury.