When applying restraints on a client, the nurse would secure a doctor's order and:
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 frequent 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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