Question

The nurse is caring for an adult client who is in soft wrist restraints. Which nursing actions should be included in the plan of care?

a) Remove restraints every 2 hours for range of motion exercises
b) Keep the restraints tight to prevent movement
c) Document the client's response to the restraints
d) Apply the restraints with a quick-release knot

Answer 1

In caring for a patient with soft wrist restraints, a nurse should remove the restraints for exercises, document the patient's response, and use a quick-release knot. Restraints must not be overly tight.

Step-by-step explanation:

When caring for an adult client who is in soft wrist restraints, the nurse has several important responsibilities to ensure the safety and well-being of the patient. The nurse should:

• Remove the restraints every 2 hours for range of motion exercises to maintain circulation and prevent muscle stiffness.
• Document the client's response to the restraints, including any signs of distress or discomfort.
• Apply the restraints using a quick-release knot to ensure they can be removed rapidly in case of an emergency.

Keeping the restraints tight to prevent movement is incorrect and can cause harm to the patient. Instead, restraints should be snug yet comfortable. The nurse should also monitor skin integrity, circulation, and the patient's overall condition regularly.