Free NCLEX-PN Practice Questions Practice Question
The nurse is providing home care to a confused client. The client's family is using a restraint to keep the client from pulling out her indwelling catheter. What should the nurse plan to include when teaching the family?
Correct Answer: B
Rationale: Option B is essential as it emphasizes the need for regular monitoring of the restrained extremities to ensure proper circulation and prevent complications like pressure ulcers or nerve damage.
Option A is incorrect because removing restraints for set periods may not adequately address the risk of injury or discomfort.
Option C is misleading; restraints should not be removed solely based on the presence of someone else, as this does not ensure the client’s safety or well-being.
Option D is also inappropriate, as it suggests that restraints can only be removed by a nurse, which could lead to prolonged discomfort and neglect of the client’s needs. Regular checks and careful monitoring are crucial for maintaining safety and dignity.
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