A nurse is planning care for a client who has a newly placed percutaneous endoscopic gastrostomy (PEG) tube and is agitated and confused. The provider prescribes bilateral wrist restraints. Which of the following actions should the nurse plan to take?

Rationale A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding. B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation. C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety. D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.