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    Ati rn pediatrics 2023 proctored exam

    A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. A quick-release knot allows for the restraints to be removed swiftly in case of an emergency. This is important to ensure that the child can be freed quickly if needed, such as if there is a sudden change in the child’s condition or an emergency arises. B. This is not adequate for ensuring the child’s safety. Regular assessments are critical for monitoring the child's physical condition, circulation, and overall comfort while in restraints. Typically, the child should be assessed at least every 15-30 minutes, depending on the facility’s policy and the child’s condition, to prevent complications such as skin breakdown, impaired circulation, or increased distress. C. The renewal of a restraint order typically must occur more frequently than every 48 hours. According to most regulations and facility policies, restraint orders are usually valid for a shorter period, often 24 hours, and must be renewed daily by a provider. D. This is not appropriate and can be dangerous. Restraints should never be tied to bed rails because this can cause serious injury if the child moves or if there is any sudden movement of the bed. Instead, restraints should be secured to a part of the bed frame that moves with the bed and does not pose a risk of injury. Proper restraint attachment helps avoid entrapment and injury.

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