A nurse is caring for an agitated post-operative patient who is pulling at the IV and surgical drain. Per Join…

Question

A nurse is caring for an agitated post-operative patient who is pulling at the IV and surgical drain. Per Joint Commission and CMS standards, which action reflects the appropriate use of restraints?

Accepted Answer

Option 2: Try least-restrictive alternatives first — sitter, family presence, environmental modification, redirection, mitten covers, or low-bed alarm — and use restraints only as a last resort with provider order, with the goal of removing them at the earliest possible time.

Joint Commission and CMS regulations require LEAST-restrictive interventions first: sitter, family presence, environmental modification, redirection, sensory aids, mitten covers, and low-bed alarms. Restraints are a last resort with: a provider order (renewed within strict time limits — 4 h adults, 2 h adolescents, 1 h children for behavioral; 24 h for non-violent), a documented evaluation, every-2-hour reassessment with circulation/skin/ROM checks and offered fluids/toileting, and removal at the earliest opportunity. Choice 1 skips less-restrictive options. Choice 3 with all 4 rails up is itself a restraint and a fall hazard. Choice 4 contradicts evidence — family presence often calms patients.

Answer

Option 1: Apply bilateral wrist restraints immediately to prevent line dislodgement.

Answer

Option 3: Place the bed in the highest position with all 4 side rails up at all times to prevent the patient from getting out of bed.

Answer

Option 4: Tell the family to leave the room because their presence is increasing the patient's agitation.

A nurse is caring for an agitated post-operative patient who is pulling at the IV and surgical drain. Per Joint Commission and CMS standards, which action reflects the appropriate use of restraints?

In-depth explanation

Clinical scenario

Key concepts

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A nurse is caring for an agitated post-operative patient who is pulling at the IV and surgical drain. Per Joint Commission and CMS standards, which action reflects the appropriate use of restraints?

In-depth explanation

Clinical scenario

Key concepts

Master the NCLEX-RN with MyMerci