The client has been placed in wrist restraints at 5:00 pm. Which of the following times best indicates when the restraints should be removed to allow range of motion activities for this client?

The client has been placed in wrist restraints at 5:00 pm. Which of the following times best indicates when the restraints should be removed to allow range of motion activities for this client?

• A. 5:30 pm
• B. 7:00 pm
• C. Next change of shift
• D. When use of restraints is no longer needed

Answer: (B)

Restraints must be released at regular intervals to allow range-of-motion activities and to assess circulation, sensation, and skin integrity. In most settings, that release occurs at least every two hours. Since the client was restrained at 5:00 pm, the earliest appropriate time to remove them for ROM and assessment is 7:00 pm. Releasing at 5:30 pm would be too soon to meet the two-hour minimum, while waiting until the next shift or until the restraints are no longer needed would miss timely assessment and could prolong risk of complications. When released, perform range-of-motion exercises, monitor neurovascular status, check the skin, reassess the need for restraints, and document the findings and plan.

Restraints must be released at regular intervals to allow range-of-motion activities and to assess circulation, sensation, and skin integrity. In most settings, that release occurs at least every two hours. Since the client was restrained at 5:00 pm, the earliest appropriate time to remove them for ROM and assessment is 7:00 pm. Releasing at 5:30 pm would be too soon to meet the two-hour minimum, while waiting until the next shift or until the restraints are no longer needed would miss timely assessment and could prolong risk of complications. When released, perform range-of-motion exercises, monitor neurovascular status, check the skin, reassess the need for restraints, and document the findings and plan.