Practice Quiz

NCLEX-RN

Category - Safety

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A nursing assistant is tasked to check a client with wrist restraints regularly. The nurse should instruct the nursing assistant to monitor the client for redness, skin breakdown, sensation, and movement of the restrained hands:
  1. Every 30 minutes
  2. Every two hours
  3. Every four hours
  4. Every shift
Explanation
Answer: A - The nurse should instruct the nursing assistant to assess the skin integrity every 30 minutes. The restraints are removed every two hours to avoid skin breakdown and impairment in movement and sensation. The nurse and nursing assistant should follow the policies and guidelines of restraint use provided by the institution.
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