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NCLEX Cheat Sheet Safety FALL 2024 £20.86
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NCLEX Cheat Sheet Safety FALL 2024
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  • NCLEX Cheat Sheet Safety
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  • NCLEX Cheat Sheet Safety

Safety 1. Restraints Restraints are a last resort and are only used when the following criteria have been met:  1. Client poses a threat to self or others (pulling at IV lines or urinary catheter, violent behavior).  2. Less restrictive measures have failed (distraction, reorientation, ...

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Document information

  • November 18, 2024
  • 7
  • 2024/2025
  • Other
  • Unknown

Subjects

  • nclex cheat sheet safety fall 2024

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  • NCLEX Cheat Sheet Safety
  • NCLEX Cheat Sheet Safety

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Table of Contents:
1. Restraints
3. Home Safety
2. Fall
4. Environmental Safety
Prevention




Safety
1. Restraints
Restraints are a last resort and Restraints are only used as a last resort if
FIGURE 1. SOFT EXTREMITY RESTRAINTS
are only used when the following there is risk for harm and only after less
criteria have been met: restrictive measures have failed.
1. Client poses a threat to self
or others (pulling at IV lines or
urinary catheter, violent
behavior).
2. Less restrictive measures
have failed (distraction,
reorientation, increased
supervision).
Restraint types:
 Physical restraints: Vest,
mittens, soft extremity
(FIGURE 1)
 Chemical restraints:
Sedatives, hypnotic
medications
Restraint selection:
 Choose the least restrictive
restraint, restricting only
necessary body parts.
 Restraint should not interfere with
treatment or worsen health
problems (no extremity
restraints on an ischemic limb).
Restraint use:
Requires an HCP order
Cannot be a PRN or standing order
 Discontinue as soon as possible.
Secure restraint using a quick-release knot for
rapid removal in an emergency (see FIGURE 1).
Secure to bed frame (not bed rails) (see FIGURE
1).

,  Assess client and remove restraints at least
every 2 hours to:
Ensure 2 fingers can be inserted
between restraint and skin (see FIGURE 1).
Assess neurovascular status distal to
restraint (skin color, temperature, pulse).
 Prevent complications like suffocation
and skin breakdown.
 Perform ROM exercises, feeding, and
toileting.
 Document client’s response to restraint.




@ For clients in restraints, perform neurovascular
assessments every 2 hours, checking skin
color,
temperature, and pulse. Ensure you can fit
the restraint.

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