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NCLEX · Safety and Infection Control

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

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

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 Tie restraints to the side rails
  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 Apply them and check once per shift
  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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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, isolation set-up, sterile technique, error prevention, restraints, and emergency and disaster response. This is one of 24 RN: Safe and Effective Care Environment questions on safety and infection control, each with a full explanation on a single study page.

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