The nurse is caring for a patient who is combative and confused. The patient has a fractured hip and is trying to get out of bed. What is the most appropriate action for the nurse to take?
A) Leave the patient and get help
B) Obtain a physician's order to restrain the patient
C) Read the facility's policy on restraints
D) Order soft restraints from the storeroom
Ans: B
Feedback: It is mandatory in most settings to have a physician's order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) and the Centers for Medicare and Medicaid Services (CMS) have designated standards for the use of restraints. A patient should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. This makes all other answers incorrect.
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