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NCLEX · General

A patient has soft wrist restraints ordered. How frequently must the nurse document assessment of the restrained extremities?

Correct answer

At minimum every 1-2 hours (per most facility policies and TJC/CMS standards) — check circulation, sensation, and skin integrity; provide ROM exercises; offer toileting and hydration; document assessment

  1. A Every 8 hours
  2. B Every 4 hours
  3. C At minimum every 1-2 hours (per most facility policies and TJC/CMS standards) — check circulation, sensation, and skin integrity; provide ROM exercises; offer toileting and hydration; document assessment
  4. D Only when something seems wrong

Why this is the answer

RESTRAINT MONITORING REQUIREMENTS: Facilities must comply with Joint Commission (TJC) and CMS standards for patients in restraints. MINIMUM STANDARDS: Assessment every 1-2 hours; WHAT TO ASSESS EACH TIME: Circulation (pulses, capillary refill, colour of fingers); Sensation (can the patient feel normal touch?); Skin integrity (any redness, abrasions, blistering from the restraint); Range of motion (provide passive or active ROM exercises); Offer toileting and repositioning; PSYCHOLOGICAL COMFORT: The patient's psychological status — are they distressed? confused?; RELEASE RESTRAINTS: For at least 10-15 minutes every 1-2 hours for ROM and care; DOCUMENTATION: Precise time-stamped documentation of each assessment. Restraints require a current physician/NP order; reassessment by the ordering provider is required daily. Restraints are never a substitute for staffing or nursing assessment.
Source: NCLEX-PN, Restraint Monitoring

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