Section: NCLEX

Question 36 of 49

36) An 84-year-old man is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tube. An order for cloth-wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate?

Attach the ties of the restraint to the bed frame.
Perform circulation checks to the extremities, which are restrained once a shift.
Remove the restraints when the patient is up in a wheelchair.
Explain the need for the restraints only to the family.

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