💊 NCLEX-RN Exam Prep

A confused patient attempts to pull out an IV line multiple times. The nurse has tried alternatives like distraction and reorientation. What is the next appropriate action regarding restraints?

A Apply wrist restraints immediately to prevent line dislodgement.
B Request a physician's order for the least restrictive restraints available.
C Document the patient's behavior and notify the charge nurse.
D Ask the family to stay at the bedside to monitor the patient.

✓ Correct Answer: Option B

Restraints should only be used as a last resort, after less restrictive measures fail. A physician's order for the least restrictive type and duration is required, following hospital policy and assessment.

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