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NCLEX Question of the Day
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A nurse is caring for a client who has wrist restraints applied due to agitation and pulling at their IV lines. Which nursing action is essential for ensuring client safety?
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Secure the restraint straps to the side rails of the bed.
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Ensure the restraints are tight enough to prevent any wrist movement.
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Correct answer Check capillary refill and skin integrity of the restrained extremities every 2 hours.
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Discontinue the restraints as soon as the client falls asleep.
Rationale
Clients with physical restraints are at risk for neurovascular injury and skin breakdown. Frequent assessment (typically every 2 hours, per facility policy) of the restrained extremities, including circulation (capillary refill, pulses, temperature, color) and skin integrity, is crucial to prevent complications. Regular release of restraints and range-of-motion exercises are also required.
Restraint straps must *never* be secured to movable parts of the bed like side rails, as this can cause injury if the rail position changes; they should be tied to the bed frame using a quick-release knot. Restraints should be snug but allow two fingers to fit underneath to prevent neurovascular compromise; preventing all movement is not the goal and increases risk. Restraints should be discontinued at the earliest possible time based on reassessment of the client's behavior and need, not simply when the client falls asleep, as the agitation may resume upon waking.
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