The nurse is applying restraints to a client. After securing a health care provider's order, what should the nurse do?
1. Assess the restraints every 10 minutes.
2. Pad bony prominences.
3. Secure the restraint to the side rail.
4. Tie the restraint with a square knot.
Correct Answer: 2
Rationale 1: The restraints should be assessed according to agency policy but no less frequently than every 2 hours.
Rationale 2: Padding bony prominences will prevent possible skin breakdown.
Rationale 3: Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head.
Rationale 4: When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled.
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