NCLEX-RN

Category - Safety

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A nurse instructs the LPN to assess an older client with hand restraints. The nurse gives the correct order if which instruction is specified:

Assess skin integrity every 30 minutes; remove the restraint at least every 4 hours
Assess skin integrity every 30 minutes; remove the restraint at least every 2 hours
Assess skin integrity every hour; remove the restraint at least every 2 hours
Assess skin integrity every hour; remove the restraint at least every hour

Explanation

Answer: B - Assessment of skin integrity and neurovascular and circulatory status should be done every 30 minutes. The restraints should be removed every 2 hours to allow exercises and to promote circulation.

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