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NCLEX · Safety and Infection Control

A client with acute confusion (delirium) is trying to get out of bed and has multiple IV lines and a Foley catheter. After attempting re-orientation and distraction, the nurse is considering restraints. What is the correct process?

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Correct answer

Exhaust all least-restrictive alternatives first; obtain a physician's order (required in all states); use the least restrictive restraint appropriate; reassess every 2 hours; provide range of motion, hydration, and skin checks; re-evaluate the need at least every 24 hours

  1. A Exhaust all least-restrictive alternatives first; obtain a physician's order (required in all states); use the least restrictive restraint appropriate; reassess every 2 hours; provide range of motion, hydration, and skin checks; re-evaluate the need at least every 24 hours
  2. B Any nurse can apply any type of restraint without an order
  3. C Apply soft wrist restraints and check in 8 hours
  4. D Apply restraints whenever a confused client tries to move

Why this is the answer

RESTRAINT USE — REGULATORY REQUIREMENTS:

Last resort: Restraints must be used only after less-restrictive alternatives fail (redirection, re-orientation, family presence, positioning, medication review, activity).

Physician order required: No nurse may initiate restraints without an order (except in emergency to protect from immediate harm — then get retroactive order within 1 hour).

Order expiration: Most states require new orders every 24 hours; TJC requires specific restraint re-evaluation every 24 hours.

Monitoring: Every 2 hours — circulation checks (pulses, sensation, warmth distal to restraint); skin integrity; position changes; offer fluids; provide ROM.

Documentation: Rationale; alternatives tried; type of restraint; client/family education; reassessment.

Prohibited: Restraints as convenience (staffing shortages); punishment; restraints that restrict breathing.

Legal/regulatory: CMS Conditions of Participation regulate restraint use in Medicare/Medicaid facilities; violations carry serious penalties.

Pn scope: Apply and monitor ordered restraints; exhaust alternatives; document; notify RN of any adverse findings.

Source: NCLEX-PN Safe Care — Restraints, Process and Legal Requirements

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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, hand hygiene, fall and injury prevention, restraints, fire safety and handling hazardous materials. This is one of 35 PN: Coordinated Care questions on safety and infection control, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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