The nurse is caring for a client that is disoriented. the nurse places the client in soft wrist restraints to discourage pulling at a nasogastric tube: the correct:
A. Within minutes of applying restraint, get an order from a qualified supplier.
C. Every two hours, assess the skin's state and circulation.
D. Provide opportunities for toileting on a regular, frequent basis.
Within minutes of applying a constraint, a licensed health care provider must provide an order for restraints. Nursing assessments of the restrained client's vital signs, circulation, skin condition or symptoms of injury, psychological status and comfort, and preparedness for ending the restraint must be conducted often and regularly. The family must be informed of the need for restraints by the nurse. Restraints must be taken off after assessment results show that the client has improved.
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