The nurse is providing care to a client requiring restraints. How often should the nurse assess the client and document the assessment?
1. Once per shift
2. Once a day
3. Once every 4–6 hours
4. Once every 1–2 hours
4
Rationale 1: Once per shift is very dangerous, and would not meet the recommendations of close observation of restrained clients.
Rationale 2: Once per day is very dangerous, and would not meet the recommendations of close observation of restrained clients.
Rationale 3: Assessing the client every 4–6 hours is not safe, and could result in client injury.
Rationale 4: Although each facility will set its own rules for frequency of assessing and documenting the use of restraints, clients generally will need to be assessed at least once every 1–2 hours.
Global Rationale: Although each facility will set its own rules for frequency of assessing and documenting the use of restraints, clients generally will need to be assessed at least once every 1–2 hours. Once per day or per shift is very dangerous, and would not meet the recommendations of close observation of restrained clients. Assessing the client every 4–6 hours is not safe, and could result in client injury.
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