A Nurse Obtains an Order from a Physician to Restrain

Multiple Choice

A nurse obtains an order from a physician to restrain a client by using a jacket restraint and delegates a nursing assistant to assist in the restraining of the client. Which of the following observations indicates inappropriate application of the restraint by the nursing assistant?

A) A safety knot in the restraint straps
B) Restraint straps that are safely secured to the side rails
C) Jacket restraint straps that do not tighten when force is applied against them
D) Jacket restraint secured so that two fingers can slide easily between the restraint and the client's skin