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A Client in the Intensive Care Unit Is Combative and Pulling

Question 23

Multiple Choice

A client in the intensive care unit is combative and pulling at the endotracheal tube, which must remain in place. After exhausting all alternatives, the nurse applies soft restraints to protect the client's airway. Which action should the nurse take next?


A) Notify the primary healthcare provider.
B) Notify the family of the need for restraints.
C) Reassess the need for the restraints in 8 hours.
D) Document the application of restraints in the chart.

Correct Answer:

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