مريض مقيّد اليدين بأمر الطبيب. أي تصرف من مساعد التمريض يحتاج تدخل الممرضة؟

A client is in wrist restraints by order. Which action by the nursing assistant requires the nurse to intervene?

1. Leaving two fingers’ space between restraint and wrist
2. Releasing it every 2 hours and moving the joint
3. Tying it to the bed frame with a quick-release knot
4. Tying the restraint to the movable side rail

Answer: D) Tying the restraint to the movable side rail. Tying a restraint to a side rail is dangerous because lowering the rail yanks the limb and injures the client. Restraints are tied to the fixed frame with a quick-release knot, allow two fingers’ space and are released regularly to check skin and circulation and move the joint.