The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which criteria must occur to ensure proper use of these restraints? Select all answers that apply
A) The nurse must check the restraints every 15 minutes while they are in place.
B) Secure the restraints with ties to the side rails, not the bed or crib frame.
C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement.
D) Use a clove-hitch type of knot to secure the restraints with ties.
E) Remove the restraint every 2 hours to allow for range of motion and repositioning.
F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
Ans: D, E, F
The nurse should use a clove-hitch type of knot to secure the restraints with ties, remove the restraint every 2 hours to allow for range of motion and repositioning, and encourage parent participation, providing continuous explanations about the reasons and time frame for the restraints. The nurse must check restraints 15 minutes following initial placement and then every hour for proper placement and secure the restraints with ties to the bed or crib frame, not the side rails. The nurse should also assess the temperature of the affected extremities, pulses, and capillary refill, initially after 15 minutes and then every hour after placement.
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