Question

A charge nurse is planning care for a client who has mechanical restraints in place. Which of the following interventions should the nurse include in the plan?

A) Remove the restraints during mealtime
B) Document the client's behavior every 4 hours
C) Release the restraints every 2 hours for repositioning
D) Apply the restraints with enough slack to allow movement

Answer 1

The nurse should include the intervention of releasing the restraints every 2 hours for repositioning in the care plan.

Step-by-step explanation:

The correct intervention that the nurse should include in the plan is to release the restraints every 2 hours for repositioning. This intervention is important to prevent complications such as skin breakdown and promote circulation and comfort for the client. Removing the restraints during mealtime can compromise the client's safety, as they may require assistance or monitoring during that time. Documenting the client's behavior every 4 hours is necessary, but releasing the restraints for repositioning is a more immediate and direct intervention.