Crucial Exams

NCLEX RN Practice Question

A nurse is caring for a client with severe agitation who has been attempting to pull out their intravenous (IV) line. The health care provider orders the use of wrist restraints. Which action should the nurse prioritize to ensure appropriate use of the restraints?

  • Document the restraint use initially, including the reason for its application, and provide updates as needed.

  • Use the minimum size restraint available to ensure the client cannot remove the device.

  • Apply the restraints promptly and obtain an order from the health care provider afterward.

  • Assess the client's skin condition, circulation, and comfort at regular intervals while the restraints are in use.

NCLEX RN
Safe and Effective Care Environment
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