A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

The correct answer is D. Release restraints every 2 hours for client to exercise. (A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and…

Safe and Effective Care Environment: Safety and Infection Control

Question

Options

AGive fluids if the client requests them.
BAssess skin integrity and circulation of extremities before applying restraints and as they are
CMeasure vital signs at least every 4 hours.
DRelease restraints every 2 hours for client to exercise.

How the community answered

(15 responses)

B
7% (1)
D
93% (14)

Explanation

(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly while the client is restrained, not only before restraints are applied and after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D) Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.

Topics

#physical restraints#restraint protocol#patient safety#circulation monitoring

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