# A confused client repeatedly reaches for a nasogastric tube, and wrist restraints are prescribed after less restrictive measures fail. For each group, select all responses that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620053&lang=en  
> language: en  
> subject: Use of Restraints/Safety Devices  
> category: SIPC

## Question

A confused client repeatedly reaches for a nasogastric tube, and wrist restraints are prescribed after less restrictive measures fail. For each group, select all responses that apply.

Before applying restraints

Assess unmet needs and document less restrictive measures already attempted

Treat family consent as a substitute for the required restraint order

Verify the current order, indication, restraint type, and time limits

Give a sedative solely to make restraint application easier

While restraints are in use

Assess skin, circulation, sensation, and range of motion at required intervals

Tie the restraint to a movable side rail

Document behavior and reassess the need for continued restraint

Place the call system out of reach to prevent repeated use

## Explanation

Before restraint use, assess unmet needs, document attempted alternatives, and verify the current order and limits. Sedation is not a substitute for restraint assessment, and family consent does not replace the authorized order and facility process. During use, perform and document frequent skin, circulation, sensation, range-of-motion, behavior, and continued-need assessments. Never secure a restraint to a side rail or remove access to the call system.

## In-depth explanation

Quick answer
Before restraint use, assess unmet needs, document attempted alternatives, and verify the current order and limits. Sedation is not a substitute for restraint assessment, and family consent does not replace the authorized order and facility process. During use, perform and document frequent skin, circulation, sensation, range-of-motion, behavior, and continued-need assessments. Never secure a restraint to a side rail or remove access to the call system.
Key cues
Use only the findings, timing, and orders stated in the scenario.
Clinical reasoning
Apply the requested nursing decision to this client rather than relying on a broad disease label.
Why the alternatives do not fit
The remaining responses are contradicted by the scenario, mistimed, outside scope, or unsafe.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
Choose only actions supported at this exact point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

A confused client repeatedly reaches for a nasogastric tube, and wrist restraints are prescribed after less restrictive measures fail. For each group, select all responses that apply.

## Key concepts

- **restraints** — restraints is a key clinical concept for assessing and managing restraint safety.
- **neurovascular assessment** — neurovascular assessment is a key clinical concept for assessing and managing restraint safety.
- **range-of-motion** — range-of-motion is a key clinical concept for assessing and managing restraint safety.

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