A nurse is caring for a client who has to be prevented from scratching an open wound. The physician has ordered wrist restraints for the client. What should the nurse do when restraining the client's hands using soft wrist protective devices?

Question

A) Bring both ends of the tie together and attach them to the side rails.
B) Apply the padded portion of the device around the wrist.
C) Attach both straps on the same side of the chair.
D) Attach the restraint only to the wrist closest to the wound.

Answer 1

B
Feedback:
The nurse should apply the padded portion of the device around the wrist to prevent skin breakdown or circulatory impairment. The nurse should not bring both ends of the tie together and attach them to the side rails. This could injure the client if the rails are moved up or down. The nurse should not attach both the straps on the same side of the chair because the client could turn, fall out of the chair, or be choked by the straps. It is dangerous to attach the restraint only to the wrist closest to the wound; it is important to secure both the wrists to prevent the client from getting entangled in the straps.