# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=en > language: en > subject: Standard/Transmission-Based Precautions/Surgical Asepsis > category: SIPC ## Question 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. ## Explanation A standing order for agitation, use for staff workflow, and securing a strap to a movable side rail require follow-up. Restraints need a current clinical reason, safe technique, and prompt discontinuation. ## In-depth explanation Quick answer Highlight the standing order for agitation, the decision to restrain because repeated calls interrupt work, and the strap secured to a movable side rail. These practices lack an acceptable individualized basis or create preventable injury risk. Why this is correct Restraints may be used only for immediate safety after less restrictive measures are ineffective, must follow an authorized order and safe technique, and must end as soon as the unsafe situation resolves. Standing orders and staff convenience do not meet those requirements.[2] Easy analogy or mental picture Think of a restraint as an emergency bridge that is opened only while the regular road is unsafe. It needs a specific reason, frequent checks, and removal as soon as the road clears. The analogy does not replace the facility's monitoring intervals or state law. Memory hook Specific danger, least restriction, safe attachment, earliest release. NCLEX decision rule For restraint questions, ask four things in order: Is there an immediate safety threat, were less restrictive measures ineffective, is the technique and order valid, and can the restraint now be removed? Convenience never substitutes for a clinical indication. Why the other choices are wrong A sitter trial, an individualized order after alternatives fail, circulation checks, range-of-motion care, a revised plan of care, and discontinuation once danger resolves all support safer and less restrictive care. Their adequacy still depends on policy and ongoing assessment, but the displayed actions do not show the target violations.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]CMS: State Operations Manual Appendix A, Patient RightsCenters for Medicare & Medicaid Services ## Related questions - [A nurse is caring for a client newly admitted with suspected methicillin-resistant Staphyl…](https://mymerci.kr/pages/nclex_q.php?qn_id=360517&lang=en) - [A nurse is about to enter the room of a client with Clostridioides difficile infection dur…](https://mymerci.kr/pages/nclex_q.php?qn_id=361226&lang=en) - [A 22-year-old female client presents to the emergency department with a 4-week history of …](https://mymerci.kr/pages/nclex_q.php?qn_id=361677&lang=en) - [A 65-year-old client admitted to the medical ICU with sepsis and acute delirium has just p…](https://mymerci.kr/pages/nclex_q.php?qn_id=361679&lang=en) - [A new graduate registered nurse (RN) on a medical unit just hung an intravenous antibiotic…](https://mymerci.kr/pages/nclex_q.php?qn_id=361710&lang=en) - [A nurse is caring for a client newly admitted with active Clostridioides difficile infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=363996&lang=en) - [A nurse is caring for an adult client newly admitted with suspected active pulmonary tuber…](https://mymerci.kr/pages/nclex_q.php?qn_id=366306&lang=en) - [A nurse cares for a client newly admitted with a positive surveillance culture for vancomy…](https://mymerci.kr/pages/nclex_q.php?qn_id=366709&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=556749&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._