A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next?

Question

Quizplus · Accepted Answer

A)Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
B)Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
C)Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.
D)Restraints can only be applied under the order of a physician. When there is an urgency to protect the client and others, restraints can be applied and then the physician should be notified immediately to write an order for the restraints. The nurse would notify the family if present, but that is not the legal priority. The nurse would document the use of restraints as soon as possible after notifying the primary healthcare provider. Most agencies require reassessment of need every 1-2 hours.

A Client in the Intensive Care Unit Is Combative and Pulling