Question

A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? 

•  Remove the restraints every 3 hr. 

•  Remove one restraint at a time. 

•  Secure restraints with a square knot. 

•  Tie the restraints to the side rail

Answer 1

A restraint is any physical or chemical constraint used by the medical staff to prevent the risk of patient harming himself or others.

The nurse should check and remove restraints every 2 hourly. She should use slip knot for the restraint instead of square knot.

The restraints should always be tied to the movable part of the bed so that they dont get tight with patient mobilization. Never tie them to side rails of bed.

The answer is “remove one restraint at a time”