A Client in the Intensive Care Unit Is Combative and Pulling

A client in the intensive care unit is combative and pulling at the endotracheal tube,which must remain in place.After applying soft hand restraints to protect the client's airway,which action should the nurse take next?

A) Notify the primary healthcare provider.
B) Notify the family of the need for restraints.
C) Reassess the need for the restraints in 8 hours.
D) Document the application of restraints in the chart.

Correct Answer:

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