The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV...

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.

1. Document the behavior(s) that require continued use of the restraints.

2. Ensure that the restraints are tied to the side rails.

 3. Provide range-of-motion exercises when the restraints are removed.

4. Orient the client.

5. Assess the tightness of the restraints.