NCLEX-RNManagement of CareHard
A confused older adult client repeatedly attempts to pull out an IV line and climb out of bed unassisted despite frequent reorientation and bed alarm use. The physician orders bilateral wrist restraints. Which nursing action is most important to ensure the client's legal rights are protected?
- ALeave the restraints in place until the client is discharged
- BApply the restraints and document the order in the chart
- CObtain a new restraint order every 24 hours and reassess the need for restraints regularly
- DRestrain the client until the family requests removal
Show answer & explanationAnswer & explanation
Correct answer: C. Obtain a new restraint order every 24 hours and reassess the need for restraints regularly
Restraints require an order with a specific time limit, regular reassessment of the least restrictive alternative, and renewal per facility policy (commonly every 24 hours for non-behavioral restraints), along with frequent monitoring of circulation and skin integrity. Restraints cannot be applied indefinitely or left to family discretion.
Why the other options are wrong
- A. Restraints must be reassessed regularly, not left in place until discharge.
- B. Simply applying and documenting the order is insufficient without ongoing reassessment.
- D. Removal should be based on clinical reassessment, not family request alone.
Restraint Use & Client Rights
Restraints are a last resort requiring a time-limited physician order, regular reassessment, and documentation of less restrictive measures tried first, to protect client rights and safety.
- Restraint orders are time-limited and must be renewed per policy
- Nurse must reassess circulation, skin, and need for restraint frequently (e.g., every 2 hours)
- Least restrictive alternative must be tried and documented first
Memory trick: Restrain last, reassess always