The nurse should perform which intervention when a client is restrained?
A.
Remove the restraints and provide skin care hourly.
B.
Document the condition of the client’s skin every 3 hours.
C.
Assess the restraint every 30 minutes.
D.
Tie the restraint to the side rails.
The Answer Is:
C
This question includes an explanation.
Explanation:
The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them.Safety and Infection Control
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