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NCLEX-PN

Category - Safety

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The nurse is assigned to care for an agitated client with Alzheimer’s disease who has two-point restraints. The nurse is correct in assessing the client’s skin integrity:

Every 3 hours
Every 2 hours
Every shift
Every 30 minutes

Explanation

Answer: D - Restraints should be released every 2 hours to allow adequate mobility and range of motion. Skin integrity should be assessed every 30 minutes.

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