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NCLEX Question of the Day
Review the question, check the correct answer, and read the rationale before tomorrow's prompt arrives.
A 2-year-old child has elbow restraints applied following cleft palate repair surgery. Which nursing action is essential for maintaining safety?
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Ensure the restraints fit tightly around the child's arms.
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Secure the restraint ties to the crib side rails.
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Keep the restraints on continuously until the surgical site is fully healed.
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Correct answer Remove the restraints periodically per facility protocol to assess skin integrity and circulation.
Rationale
Restraints can impair circulation and cause skin breakdown. It is essential to remove them periodically (following facility policy, typically every 1-2 hours) to assess the underlying skin for redness or breakdown, check peripheral pulses, temperature, and capillary refill, and allow for range-of-motion exercises. Restraint ties should be secured to the bed frame using quick-release knots, not the side rails, as lowering the rails could injure the child. Restraints should be snug but not tight, allowing one or two fingers to fit underneath. Continuous application without assessment poses significant safety risks.
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