ATI Comprehensive 2023 With NGN 180 Questions And Answers | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.


Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation.
Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted.
Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.

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