Editing Infection Control and Safety – RN Practice Questions (section)

==Question 8==
A client with a nonviolent behavior indication has soft wrist restraints applied to protect an endotracheal tube. Which nursing action is '''correct'''?
# Secure the restraint ties to the side rails so the restraints move with the rails.
# Obtain a PRN order so the restraints can be reapplied overnight as needed.
# Tie the restraints to the movable bed frame using a quick-release knot and check circulation, sensation, and motion every two hours.
# Leave the restraints in place continuously until the endotracheal tube is removed.

'''Answer:''' 3. Tie the restraints to the movable bed frame using a quick-release knot and check circulation, sensation, and motion every two hours.

''Rationale:'' Restraints are secured to the movable portion of the bed frame so raising or lowering the bed does not tighten them, and a quick-release knot allows rapid removal in an emergency. Option 1 risks injury when the rail moves. Option 2 is prohibited; PRN and standing restraint orders are not permitted. Option 4 violates the requirement to release the restraint at least every two hours for range of motion, repositioning, toileting, hydration, and skin care, and to discontinue at the earliest possible time.