NCLEX-RNSafety and Infection Prevention and ControlMedium
A nurse receives a prescription to apply wrist restraints to an agitated client. Which action should the nurse prioritize immediately after applying the restraints?
- ADocumenting the type of restraint and client's behavior.
- BAssessing circulation, sensation, and movement (CSM) of the restrained extremities.
- CNotifying the client's family about the restraint application.
- DOffering the client food and fluids.
Show answer & explanationAnswer & explanation
Correct answer: B. Assessing circulation, sensation, and movement (CSM) of the restrained extremities.
Ensuring the client's physical safety and well-being is the immediate priority after applying restraints. Assessing circulation, sensation, and movement (CSM) of the restrained extremities checks for potential injury or compromise caused by the restraints, preventing complications like nerve damage or impaired blood flow.
Why the other options are wrong
- A. Documentation is important but comes after ensuring immediate client safety.
- C. Notifying the family is important but not the most immediate priority compared to direct client safety.
- D. Offering food and fluids is part of ongoing care but not the immediate priority after restraint application.
Restraint Post-Application Care
Immediate and ongoing assessments and interventions required after applying physical restraints to ensure client safety and minimize harm.
- Assess circulation, sensation, and movement (CSM) of restrained limbs immediately and regularly.
- Ensure proper fit and placement of restraints to prevent injury.
- Provide for basic needs (hydration, nutrition, hygiene, toileting) at regular intervals.
Memory trick: RESTRAIN, then CHECK, then CARE, then DOCUMENT.