An older adult client who has a history of falls has been placed in physical restraints after the failure of all other alternatives for fall prevention. What actions should the nurse take to en-sure the safety of the client in restraints?
A. Check the client every hour, while keeping the restraints in place.
B. Check the client every 30 to 60 minutes, releasing the restraints every 2 hours.
C. Check the client once each shift, releasing the restraints for feeding only.
D. Check the client twice each shift, 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.
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