ATI RN
ATI RN Fundamentals 2019 II Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Remove one restraint at a time. This is the appropriate action because it allows the nurse to maintain control over the client while ensuring safety. By removing one restraint at a time, the nurse can assess the client's behavior and determine if they are calm enough to have both restraints removed. This approach also minimizes the risk of the client becoming agitated or aggressive when both restraints are removed simultaneously.
A: Tying the restraints to the side rail restricts the client's movement and can lead to injury.
C: Securing restraints with a square knot may make it difficult to quickly remove them in case of an emergency.
D: Removing the restraints every 3 hours does not address the immediate safety concerns and may not be necessary based on the client's behavior.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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