The Nurse Is Caring for a Patient in Restraints

question 38

Multiple Choice

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.)

• A) One family member has gone to lunch.
• B) Patient is placed in bilateral wrist restraints at 0815.
• C) Bilateral radial pulses present, 2+, hands warm to touch
• D) Straps with quick-release buckle attached to bed side rails
• E) Attempts to distract the patient with television are unsuccessful.
• F) Released from restraints, active range-of-motion exercises completed

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