A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot.
Which of the following actions should the nurse take?

The correct answer is Choice C.

Choice A rationale: Using a fire extinguisher is part of containment, but it follows evacuation. Attempting to extinguish before removing clients violates RACE protocol and risks patient injury from smoke or electrical fire.

Choice B rationale: Activating the fire alarm initiates emergency response but comes after client rescue. Per RACE (Rescue, Alarm, Contain, Extinguish), client safety is prioritized before system-wide alerts.

Choice C rationale: Moving clients to safety is the first step in fire response. It aligns with the “Rescue” phase of RACE, ensuring immediate protection from smoke inhalation, electrical hazards, and fire spread.

Choice D rationale: Confine by closing doors and windows is part of containment, which follows rescue and alarm activation. It helps limit fire spread but is not the initial priority in patient-centered emergencies.

The correct answer is choice a. Retie the restraint straps with a slipknot.

Choice A rationale:

The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.

Choice B rationale:

It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.

Choice C rationale:

Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.

Choice D rationale:

The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.