💊 NCLEX-RN Exam Prep

A confused patient repeatedly attempts to remove their IV line. The nurse has exhausted all less restrictive interventions. If physical restraints are applied, what is a priority nursing action?

A Documenting the application of restraints every 8 hours.
B Removing restraints every 2 hours for skin assessment and range of motion.
C Administering a sedative to the patient to reduce agitation.
D Notifying the family immediately that restraints have been applied.

✓ Correct Answer: Option B

For patients in physical restraints, the nurse must assess and remove them at least every 2 hours for skin integrity, circulation, range of motion, and toileting to prevent complications like pressure injuries or neurovascular impairment.

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