When putting a client in restraints, the nurse will need to assess the client per policy. Which items will the nurse include when assessing this client?
1. The client's range of motion
2. That the client's restraint is tied in a knot
3. The client's vital signs
4. The client's circulation
5. The client's hydration
1,3,4,5
Rationale 1: When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion
Rationale 2: The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
Rationale 3: When the nurse is providing care to a client who is in restraints, appropriate items to assess include vital signs.
Rationale 4: When the nurse is providing care to a client who is in restraints, appropriate items to assess include circulation.
Rationale 5: When the nurse is providing care to a client who is in restraints, appropriate items to assess include hydration.
Global Rationale: When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
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