The charge nurse reviews care for a client placed in soft wrist restraints. Which practices require follow-up? Highlight the practices that do not meet restraint safety requirements.

Nurses' Notes 1410: The client became disoriented and repeatedly reached toward a newly placed arterial catheter. Staff first used reorientation and a trained observer remained at the bedside. The client continued pulling at the catheter despite these measures. At 1420, the practitioner entered an individualized restraint order after less restrictive interventions were ineffective. The order also states soft wrist restraints may be used standing for agitation throughout the admission. The nurse checks skin color, warmth, sensation, and pulses at the interval required by policy. During care, each wrist is released separately for range of motion and skin assessment. The plan of care is updated with the behavior that prompted the intervention. At 1500, another nurse states that restraints should remain because repeated call-light use interrupts medication rounds. The client is offered fluids, toileting, and repositioning. At 1530, the right restraint strap is secured to the movable side rail. The left strap is attached to the approved stationary bed location. At 1600, the client follows directions and no longer reaches for the catheter. The nurse then discontinues the restraints when the immediate safety threat has resolved. The nurse documents the response to less restrictive measures. The family receives an explanation of the current safety plan.