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NCLEX · General

When using restraints on a client (as a last resort), which nursing action is essential for safe care?

Correct answer

Obtain a provider's order, use the least restrictive type, and frequently monitor the client (circulation, skin, needs) per policy, releasing/repositioning regularly

  1. A Apply them and check once per shift
  2. B Obtain a provider's order, use the least restrictive type, and frequently monitor the client (circulation, skin, needs) per policy, releasing/repositioning regularly
  3. C Tie restraints to the side rails
  4. D Use restraints for staff convenience

Why this is the answer

RESTRAINTS are a LAST RESORT after less restrictive measures fail, used only to protect the client or others. SAFE USE requires: a PROVIDER'S ORDER (time-limited; cannot be PRN/standing; emergency application requires an order ASAP); the LEAST RESTRICTIVE type effective; FREQUENT MONITORING per policy (circulation, skin integrity, positioning, nutrition, hydration, toileting, and the continued need); releasing/repositioning at regular intervals; tying restraints to the BED FRAME (NOT side rails) with a quick-release knot; ongoing assessment and documentation. NCLEX safe care/safety. Restraints are NEVER for staff convenience or punishment. Improper restraint use causes injury/death. Knowing the strict requirements for safe restraint use is a heavily tested NCLEX safety topic.
Source: NCLEX Safe Care — Restraint Safety

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