Prior to or immediately after applying restraints, the nurse must ...

[Haya94]

Prior to or immediately after applying restraints, the nurse must document the use of restraints in the medical record. Which item is not required in the documentation for this client?
 
  1. Need for restraint was made clear to client and/or support people
  2. Why the restraint was considered necessary
  3. Type of restraint used
  4. Health care provider's order for use of restraints

Question 2

The nurse is providing care to a client requiring restraints. How often does the nurse assess the client and document the assessment?
 
  1. Once per shift
  2. Once a day
  3. Once every 4-6 hours
  4. Once every 1-2 hours

[blakeserpa]

Answer to Question 1

Correct Answer: 4

The health care provider must write the order for the use of restraints, and cannot provide a verbal or telephone order. The nurse should document the explanation provided to the client and/or support people, why the restraint was needed, and the type of restraint used.

Answer to Question 2

Correct Answer: 4

Although each facility will set its own rules for frequency of assessing and documenting the use of restraints, clients generally will need to be assessed at least once every 1-2 hours. Once per day or per shift is very dangerous, and would not meet the recommendations of close observation of restrained clients. Assessing the client every 4-6 hours is not safe, and could result in client injury.

[Haya94]

TYSM

[JaynaD87]

Excellent