If the client is placed in restraints and requires these restraints for longer than 2 hours, the nurse must carry out which of the following actions?
a. Remind the client why he or she is in restraints, and what the consequences are for what he or she did.
b. Remove the restraints for at least 5 minutes every 2 hours (one at a time), and check circulation.
c. Give the client a snack such as an apple.
d. Take off the restraints, and leave them off.
B
Restraints must be removed for at least 5 minutes every 2 hours so that the nurse can check the client's circulation in each limb. Restraints are removed and then replaced only one at a time. The nurse will not remove all restraints until the client's condition no longer poses a threat to self or others. While a client may receive a snack while in restraints, there is no requirement that the snack is given at any particular time.
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