# A confused client is in prescribed wrist restraints that were applied after less restrictive measures were tried. Which nursing action is most important while the restraints remain in place?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522684&lang=en  
> language: en  
> subject: Use of Restraints/Safety Devices  
> category: SIPC

## Question

A confused client is in prescribed wrist restraints that were applied after less restrictive measures were tried. Which nursing action is most important while the restraints remain in place?

## Option

1. Ask a family member to sit at the bedside so the restraints can stay on
2. Assess circulation and skin under each restraint and release them regularly **✔ Correct answer**
3. Secure the restraint straps to the side rails so the arms stay well aligned
4. Renew the restraint prescription at shift change and record why it is needed

**Correct answer: 2**

## Explanation

Restraints threaten circulation and skin integrity. Scheduled assessment with periodic release protects the limb and creates the chance to discontinue the restraint early.

## In-depth explanation

Quick answer
Check circulation and skin under the restraints and release them on a schedule.

Why this is correct
The harm from a restraint accumulates quietly at the point of contact. Regular assessment with release preserves perfusion and skin, and each release is also the moment to test whether the restraint is still needed.

Easy analogy or mental picture
It is like loosening a tourniquet that was never meant to stay tight. The picture stresses ongoing checks and does not suggest the restraint is removed without judgment.

Memory hook
Every restraint needs a schedule for looking and releasing.

NCLEX decision rule
While restraints are in use, assess circulation, sensation, and skin at set intervals and release periodically. Renewal and documentation are required but do not protect the limb.

Why the other choices are wrong
A bedside companion, a tidy attachment, and prescription renewal all appear in restraint care, yet none of them protects perfusion and skin during the hours the restraint is on.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]CMS: Patient Rights on Restraint and SeclusionU.S. Centers for Medicare and Medicaid Services

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