When caring for a patient who has an arm or leg restraint in place,how often will the nurse remove the restraint?
A)Every 15 minutes
B)Every 30 minutes
C)Every hour
D)Every 2 hours

Question

Quizplus · Accepted Answer

Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO],2004).If the patient is violent or noncompliant,remove one restraint at a time and/or have staff assistance while removing restraints.Removal provides an opportunity to change the patient's position,offer nutrients,perform full ROJM,and toilet and exercise the patient.After application,evaluate the patient's condition for signs of injury every 15 minutes.Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time.If the patient shows no sign of impaired circulation or other complications,the restraint does not need to be removed at this time.If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior,this presents an immediate danger;a face-to-face physician assessment is needed within 1 hour to determine the patient's need for the restraint.

When Caring for a Patient Who Has an Arm or Leg