A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse?

a. Document in the client’s chart that an incident report has been filed:

Documenting that an incident report has been filed is an important step in the process of addressing the client's complaint. It ensures that there is a record of the incident and initiates the appropriate follow-up procedures.

b. Call risk management to interview the client:

In long-term care facilities, risk management departments are responsible for investigating incidents and ensuring that appropriate measures are taken to prevent future occurrences. In this situation, involving risk management may be necessary to conduct a thorough investigation.

c. Contact the nurse manager:

The nurse manager is responsible for overseeing the nursing staff and ensuring that quality care is provided to clients. Contacting the nurse manager allows for immediate notification of the incident and enables them to initiate the appropriate steps to address the situation.

d. Reassure the client that the staff is well trained:

While it's important to provide reassurance to the client, simply reassuring them without taking any further action may not adequately address their concerns or prevent similar incidents from occurring in the future.

a. Administer a sedative to the client:

Administering a sedative may temporarily calm the client, but it should not be the first-line intervention, especially without a physician's order. Sedatives carry risks and should only be used when other interventions have been considered and deemed ineffective or when the client's behavior poses an immediate danger to themselves or others.

b. Contact a family member to come and sit with the client: could indeed be a valid first step. If a family member is available and able to assist, they could potentially calm the client without the need for isolation and reducing disruptive behavior.However, if this is not feasible, then ensuring the client’s safety through temporary isolation with frequent checks might be necessary.

c. Place the client in a wheelchair with a lap tray:

Placing the client in a wheelchair with a lap tray may restrict their movement and potentially exacerbate agitation or aggression. It does not address the underlying reasons for the behavior and may not be an appropriate intervention for managing wandering behavior.

d. Keep the client in her room with the door closed:

Isolating a client in their room could be considered a form of restraint or isolation and should be used with caution.This should be used only after other less restrictive measures have been tried and deemed ineffective.