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NCLEX · Client Rights and Advocacy

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

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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 Only when something seems wrong
  2. B 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
  3. C Every 8 hours
  4. D Every 4 hours

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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About this topic: Client Rights and Advocacy

Client rights and advocacy questions cover informed consent, refusal of treatment, confidentiality, advance directives, and the nurse's role as the client's advocate. This is one of 7 PN: Coordinated Care questions on client rights and advocacy, 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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