# 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?

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> language: en  
> subject: NCLEX-RN  
> category: MOC

## 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?

## Option

1. Apply bilateral wrist restraints immediately to prevent line dislodgement.
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. **✔ Correct answer**
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.
4. Tell the family to leave the room because their presence is increasing the patient's agitation.

**Correct answer: 2**

## Explanation

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.

## In-depth explanation

The single most-tested restraint principle is "least restrictive first, restraints as last resort, with continuous reassessment." A 4-side-rails-up bed is legally a restraint under CMS. The required documentation cycle is heavy: order, indication, alternatives tried, ongoing assessment, debrief.

## Clinical scenario

**Post-operative adult, increasingly agitated**, pulling at the IV and surgical drain despite redirection. The patient is not obtunded, has stable vitals, and the family is at the bedside. The nurse considers least-restrictive options before any restraint.

## Key concepts

- **Least-restrictive intervention** — Sitters, family, redirection, environment, sensory aids, mitten covers; tried before any restraint.
- **4-side-rail rule** — Raising all 4 side rails to confine a patient to the bed is a restraint under CMS — increases fall and injury risk.
- **Restraint reassessment** — Q15 min for behavioral restraint, Q2 h for non-violent; check circulation, skin, ROM, offer fluids/toileting; document continuously.

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