An older adult client is in physical restraints. Which intervention by the nurse is the priority?
a. Assess the client hourly while keeping the restraints in place.
b. Assess the client every 30 to 60 minutes, releasing restraints every 2 hours.
c. Assess the client once each shift, releasing the restraints for feeding.
d. Assess the client twice each shift while keeping the restraints in place.
B
The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in re-straints.
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