NCLEX-PN® ExaminationSafety and Infection ControlHard
An LPN is caring for a client who has a history of falls and is exhibiting increased agitation. The LPN has implemented all less restrictive interventions, but the client continues to attempt to get out of bed unsupervised. The LPN obtains an order for bilateral wrist restraints. What is the priority nursing action after applying the restraints?
- ADocument the time of restraint application and the client's behavior.
- BEnsure the restraints are tied to the bed frame, not the side rails.
- CAssess skin integrity and neurovascular status of the restrained extremities.
- DReorient the client to their surroundings and explain the purpose of the restraints.
Show answer & explanationAnswer & explanation
Correct answer: C. Assess skin integrity and neurovascular status of the restrained extremities.
After applying restraints, the immediate priority is to assess the client's physical safety. Checking skin integrity and neurovascular status (circulation, sensation, movement) of the restrained extremities is crucial to prevent complications such as nerve damage, impaired circulation, and skin breakdown, which can occur rapidly.
Why the other options are wrong
- A. Documentation is important but not the *immediate* priority over client physiological safety.
- B. Tying to the bed frame is a correct technique, but assessing the client's physical status takes precedence immediately after application.
- D. Reorientation and explanation are important for client understanding and comfort, but physical assessment for safety is the *priority* immediately after application.
Restraint Monitoring
Regular and systematic assessment of a client's physical and psychological status while in restraints to ensure safety and minimize adverse effects.
- Assess neurovascular status (CSM: circulation, sensation, movement) every 15-30 minutes.
- Check skin integrity under and around restraints.
- Provide range of motion, toileting, nutrition, and hydration every 2 hours.
- Reassess need for restraints frequently.
Memory trick: Restrained? Check the Blood Flow, Don't Let Injury Grow!