A physician orders restraints for a confused client who is at risk for injury by pulling out tubes necessary to sustain her life. Which of the following statements describes an accurate action to take when applying these restraints?
A) Apply restraints to the hands or wrists, never to the ankles.
B) Ensure that two fingers can be inserted between the restraint and the client's extremity.
C) Use a quick-release knot to tie the restraint to the side rail.
D) Remove the restraint at least every four hours, or according to agency policy.
Ans: B
Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every two hours.
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