A client with delirium who is receiving mechanical ventilation keeps reaching for the endotracheal tube despite less restrictive measures. Soft wrist restraints have been prescribed. Which actions by the nurse are appropriate? Select all that apply.
- AVerify that the prescription specifies the type of restraint and a time limit.
- BTie the restraint straps to the bed's side rails.
- CSecure the straps to a part of the bed frame that moves with the client, using quick-release ties.
- DAsk the provider to write the restraint prescription as needed (PRN) for future agitation.
- ECheck circulation, skin, and comfort of the restrained wrists at regular intervals.
- FReassess the client regularly so the restraints can be removed at the earliest possible time.
Show answer and explanations
Answer
A, C, E, F
A: The order must meet restraint type and duration requirements. B: Side rails can move and create unsafe restraint tension. C: An appropriate bed-frame attachment and quick release support safe application. D: PRN restraint orders are not an appropriate substitute for current assessment and orders. E: Neurovascular, skin, and comfort checks detect harm. F: Frequent reassessment supports the earliest safe removal.
A
The order must meet restraint type and duration requirements.
B
Side rails can move and create unsafe restraint tension.
C
An appropriate bed-frame attachment and quick release support safe application.
D
PRN restraint orders are not an appropriate substitute for current assessment and orders.
E
Neurovascular, skin, and comfort checks detect harm.
F
Frequent reassessment supports the earliest safe removal.