Free NCLEX RN Practice Test Practice Question
An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.
Correct Answer: A,C,D
Rationale: When applying restraints, it's essential to first explore alternate methods (A) to ensure the client's safety and dignity. This approach promotes less restrictive interventions. Regular reassessment (C) is crucial to determine the ongoing need for restraints and to minimize potential harm. Adhering to written policies (D) ensures compliance with legal and ethical standards, protecting both the client and the healthcare provider.
In contrast, assuming that confused clients are safer in restraints (B) is misleading, as restraints can increase confusion and risk of injury. Applying the most restrictive option (E) contradicts the principle of using the least restrictive measures necessary. Lastly, the belief that an order is unnecessary if the client is in danger (F) is incorrect; restraints require a physician's order to ensure proper oversight and justification.
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