A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?

Choice A reason: PRN prescriptions for restraints are not standard, as restraints require specific orders renewed every 24 hours. PRN orders risk overuse, violating least-restraint principles. Regular assessment ensures necessity, preventing harm like circulation issues or psychological trauma in restrained clients. Choice B reason: Removing restraints based on calm behavior requires provider authorization after assessing ongoing risk. Premature removal may endanger the client or others, as agitation can recur. Restraint protocols prioritize safety, requiring clinical judgment beyond observed compliance to discontinue use. Choice C reason: Observing every 15 minutes ensures client safety, monitoring for complications like skin breakdown or circulatory impairment. Restraints pose physical and psychological risks, and frequent checks align with regulatory standards to assess behavior, necessity, and potential for de-escalation or restraint removal. Choice D reason: Hourly documentation is insufficient, as restraints require monitoring every 15 minutes to ensure safety and compliance with standards. Less frequent checks risk missing complications like pressure injuries or agitation changes, making this inadequate for safe restraint management and client care.