👤 By the CinnaRN Clinical Content Team🕐 Updated 2026-08-23🏷️ Safety & Infection Control🔖 Free to read, print, and share
Also known as: restraints · physical restraint · tying down patient · patient restraint
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Use this quick-reference guide to spot, treat, and prevent Use of Restraints on the NCLEX. Keep it handy during review and on exam day!
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📒 The 1-minute cheat sheet
📌 Rules
Least restrictive, try alternatives first
MD order required, time-limited
No PRN restraint orders
✅ Do
Quick-release knot to frame
Tie to bed frame, NOT rail
2 fingers fit under restraint
🩺 Assess
Check circ/skin q15–30 min
Release q2h: ROM, toilet, food
🚩 Report
Renew order per policy
📚 Use of Restraints — full study notes
The cheat sheet above is your quick recall card. These notes go deeper — what it is, what to do first, what must be reported, and what to teach.
Restraints are physical or chemical measures that restrict a patient's movement, used only as a last resort to protect the patient or others when less restrictive alternatives have failed. They carry serious risks including injury, strangulation, impaired circulation, aspiration, and death. Use requires a current provider order, the least restrictive type, and strict ongoing monitoring. Restraints are never used for staff convenience or punishment.
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Key points
Understand these first
Restraints require a time-limited provider order specifying type, reason, and duration; behavioral/violent restraint orders are limited and require frequent renewal.
An order can never be PRN (as needed); each episode requires its own order and an in-person evaluation within set timeframes.
Less restrictive alternatives (sitters, diversion, frequent reorientation, addressing pain/toileting) must be tried first.
A quick-release knot tied to the movable bed frame (not the side rail) allows rapid removal in an emergency.
Restrained patients need frequent assessment of circulation, skin integrity, range of motion, toileting, hydration, and nutrition.
Chemical restraint (sedating medication used to control behavior, not to treat a condition) is also a restraint and follows the same rules.
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Nursing priorities
What to do, in order
Try and document the least restrictive alternatives before applying any restraint.
Obtain a current provider order specifying type, reason, and time limit; restraints are never applied PRN.
Apply the least restrictive device, secure it to the movable bed frame with a quick-release knot, and keep two fingers' space for circulation.
Monitor circulation, skin, and positioning regularly, and release the restraint per schedule to provide range of motion, toileting, and food/fluids.
Reassess the continued need each shift and discontinue at the earliest safe opportunity, documenting behavior and interventions.
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Red flags — report now
Escalate immediately
Signs of compromised circulation (cool, pale, cyanotic, numb, or swollen extremity) require immediate removal of the restraint.
A restraint tied to a side rail or with a fixed knot is unsafe and can cause strangulation or injury; correct it immediately.
Never use restraints for staff convenience, coercion, or punishment, and never as a substitute for monitoring.
Applying or continuing restraints without a current valid order is a violation; obtain the order or remove the restraint.
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Patient teaching
What patients must know
Explain to the patient and family why the restraint is needed, that it is temporary, and the criteria for removal.
Encourage family presence and involvement, which may reduce the need for restraints.
Reassure that the patient will be checked frequently and released regularly for movement, toileting, and comfort.
❓ Use of Restraints: NCLEX FAQs
What are the priority nursing interventions for Use of Restraints?
Try and document the least restrictive alternatives before applying any restraint. Obtain a current provider order specifying type, reason, and time limit; restraints are never applied PRN. Apply the least restrictive device, secure it to the movable bed frame with a quick-release knot, and keep two fingers' space for circulation. Monitor circulation, skin, and positioning regularly, and release the restraint per schedule to provide range of motion, toileting, and food/fluids.
What are the warning signs of Use of Restraints a nurse must report?
Signs of compromised circulation (cool, pale, cyanotic, numb, or swollen extremity) require immediate removal of the restraint. A restraint tied to a side rail or with a fixed knot is unsafe and can cause strangulation or injury; correct it immediately. Never use restraints for staff convenience, coercion, or punishment, and never as a substitute for monitoring. Applying or continuing restraints without a current valid order is a violation; obtain the order or remove the restraint.
What do I need to know about Use of Restraints for the NCLEX?
Restraints require a time-limited provider order specifying type, reason, and duration; behavioral/violent restraint orders are limited and require frequent renewal. An order can never be PRN (as needed); each episode requires its own order and an in-person evaluation within set timeframes. Less restrictive alternatives (sitters, diversion, frequent reorientation, addressing pain/toileting) must be tried first. A quick-release knot tied to the movable bed frame (not the side rail) allows rapid removal in an emergency.
What patient teaching is important for Use of Restraints?
Explain to the patient and family why the restraint is needed, that it is temporary, and the criteria for removal. Encourage family presence and involvement, which may reduce the need for restraints. Reassure that the patient will be checked frequently and released regularly for movement, toileting, and comfort.
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Quick Tip
Restraints require a time-limited provider order specifying type, reason, and duration; behavioral/violent restraint orders are limited and require frequent renewal.