The nurse preceptor is caring for a patient in physical restraints who is aggressive and threatening the safety of the staff. The nurse preceptor discusses the implications and requirements of this procedure with a novice nurse
What statement made by the graduate nurse indicates that the nurse preceptor's teaching has been effective?
1. "It is acceptable for the nurse to monitor the patient in physical restraints every hour to ensure the patient's safety."
2. "It is acceptable to place the patient in physical restraints if pharmacological methods have been unsuccessful."
3. "It is acceptable for the health care provider to assess the patient in restraints within 24 hours of restraint application."
4. "It is acceptable for the nurse to turn and reposition the patient in physical restraints every 2 hours to ensure the patient's skin integrity."
Answer: 4
Explanation: Physical restraints are used only as a last resort, after all interventions have been tried and have been unsuccessful. The nurse must turn and reposition the patient in physical restraints at least every 2 hours to ensure the patient's skin integrity. The patient who is in physical restraints must be monitored constantly, not every hour, to ensure the patient's safety. All other possible interventions, not just pharmacological, must be attempted prior to the use of physical restraints. Additional interventions may include therapeutic communication techniques. Once physical restraints have been applied, the health care provider must assess the patient in restraints within 1 hour of restraint application.
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