A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?

  • move the client closer to the nursing station to allow close monitoring
  • apply the restraint in compliance with hospital policy
  • consult with a more experienced nurse on a course of action
  • check on the client every 30 minutes to ensure her safety
Number 2 is correct.
Applying the restraint is in compliance with hospital policy and, as ordered, provides for client safety. Moving the client closer to the nursing station is inadequate to provide a safe environment. The NCLEX-RN exam wants to see what the test taker would do rather than passing the responsibility to someone else. Monitoring the client consistent with hospital policy would be in addition to appropriate use of a restraining device.