A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place
After applying soft hand restraints to protect the client's airway, which action should the nurse take next?
A) Notify the primary healthcare provider.
B) Notify the family of the need for restraints.
C) Reassess the need for the restraints in 8 hours.
D) Document the application of restraints in the chart.
Answer: A
According to the law, the primary healthcare provider must see the client and write a prescription for restraints within 1 hour of application. The nurse would apply the restraints to protect the airway and then immediately notify the primary healthcare provider. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
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