NCLEX-RN Latest Exam Braindumps
Question 1: A violent client remains in restraints for several hours. Which of the following interventions ismost appropriate while he is in restraints?
A. Give fluids if the client requests them.
B. Assess skin integrity and circulation of extremities before applying restraints and as they are
removed.
C. Measure vital signs at least every 4 hours.
D. Release restraints every 2 hours for client to exercise.
Correct Answer: D
Explanation:
(A) Fluids (nourishment) should be offered at regular intervals whether the client requests (or
refuses) them or not. (B) Skin integrity and circulation of the extremities should be checked regularly
while the client is restrained, not only before restraints are applied and
after they are removed. (C) Vital signs should be checked at least every 2 hours. If the client remains
agitated in restraints, vital signs should be monitored even more closely, perhaps every 1-2 hours. (D)
Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle
tone, skin and joint integrity, and circulation.
