You are the charge nurse for this shift. Upon completing his rounds, a physician prescribes restraints for four on the floor. Upon reviewing the orders, you know that it is inappropriate to apply restraints to which of the following patients?
A) A postlaryngectomy patient attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to pull out his IV catheter
C) A patient with urosepsis who is often ringing the call bell to use the bedside commode
D) A paranoid patient who has just tried to commit suicide and is refusing restraints
Ans: C
Feedback: Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode, and this is appropriate behavior that will not result in patient harm. The situations described in options A, B, and D could result in patient harm; therefore, it is appropriate to apply restraints in these instances.
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