Hesi RN Exit Proctored Exam
Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room?
Explanation & Rationale
A. Restraints should be secure but not too tight to prevent injury or impaired circulation. B. Ensuring the knot can be quickly released is critical for the client's safety in case of emergency. C. A double turn or square knot would make the restraint difficult to remove quickly, posing a safety risk. D. Restraints should never be tied to side rails as this can cause injury if the rails are moved.
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