A confused client keeps pulling at a central line. Soft wrist restraints are applied. Which action is required?

Question

Accepted Answer

A. Obtain a provider order per policy and assess/release restraints at least every 2 hours — Restraints require a time-limited order and ongoing assessment for circulation, skin integrity, and need. Release and range-of-motion are done at scheduled intervals per policy, and detailed documentation is required.

Answer

B. Keep restraints on until morning to ensure safety

Answer

C. Tie restraints to the side rails for stability

Answer

D. Document only “client restrained” once per shift