A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Choice A Reason:
Reinforcing facility protocols at the next staff meeting, is important for reminding all staff members of the importance of following protocols, but it may not address the immediate issue at hand.
Choice B Reason:
Discussing the issue with the AP is correct. When a charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol, the first action should be to directly address the issue with the AP. This allows for immediate feedback and correction of behavior, helping to ensure that proper procedures are followed in the future.
Choice C Reason:
Alerting the infection control department, may be necessary if the violation poses a risk of infection transmission, but it may not be the first step. Directly addressing the issue with the AP allows for immediate correction and prevents potential harm.
Choice D Reason:
Notifying the unit manager about the incident, is also important, but addressing the issue with the AP directly is the immediate action needed to correct the behavior.

Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot.When applying restraints, using a square knot isessential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.