Which nursing intervention is appropriate for a client with an ARM restraint?
A. Applying the restraint loosely to prevent pressure on the skin B. Tying the restraint to the side rail C. Positioning the restrained ARM in full extension D. Monitoring circulatory status every 2 hours
Monitoring circulatory status every 2 hours-rationale: a nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. to make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. the restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.client needs category: safe, effective care environmentclient needs subcategory: safety and infection controlcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 692.