The nurse is caring for a client who was intubated during surgery and who is beginning to wake up. The client is combative and pulling at the tube, which needs to be in place
The nurse applies soft hand restraints to protect the client's airway and takes which action next? 1. Notifies the family of the need for restraints.
2. Documents the application of restraints in the chart.
3. Reassesses the need for the restraints in 3 hours.
4. Notifies the physician for an order and assessment.
4. Notifies the physician for an order and assessment.
Rationale:
According to the law, the physician must see the client and write an order within one hour of application of restraints. The nurse would apply the restraints to protect the airway and then immediately notify the physician. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the physician. Most agencies require reassessment of need every 1–2 hours.
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