A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Inform the unit manager of the incident.

Speak with the AP about the incident.

Remove the restraints from the client's wrists.

Review the chart for nonrestraint alternatives for agitation,

Answer and Explanation

The Correct Answer is C

A.   Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B.   Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C.   Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D.   Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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Correct Answer is D

Explanation

A. Implementing a fall prevention plan is an important step but comes after identifying those at risk.
B. Reviewing current literature is important for understanding evidence-based practices, but it should come after identifying and assessing the specific risk factors in the facility.
C. Notifying staff of the increased fall rate is essential but doesn't directly address the root cause; it's more reactive than proactive.
D. Identifying clients who are at risk for falls is the initial step to intervene and prevent further incidents, forming the foundation for a targeted fall prevention plan.

A. Providing a 10 min rest period prior to meals B. Elevating the head of the client's bed to 30° during mealtime C. Withholding fluids until the end of the meal D. Instructing the client to place her chin toward her chest when swallowing

Correct Answer is B

Explanation

A: Providing a 10-minute rest period prior to meals can be beneficial for some clients, but it is not specifically related to the prevention of aspiration in clients with dysphagia. Rest periods do not directly facilitate safer swallowing processes.

B: Elevating the head of the client's bed to 30° during mealtime is the correct technique for a client with dysphagia. This position helps prevent aspiration, which can occur if food or liquids enter the lungs instead of going down the esophagus. The semi-upright position aids in the proper alignment of the esophagus and reduces the risk of choking.

C: Withholding fluids until the end of the meal is not an appropriate technique for a client with dysphagia. Fluids are often needed to help swallow and clear the mouth of food particles. Additionally, providing fluids throughout the meal can help prevent dehydration.

D: Instructing the client to place her chin toward her chest when swallowing can help prevent aspiration in clients with dysphagia. However, this technique should be used in conjunction with other methods, such as the correct positioning of the bed, to ensure safety and effectiveness.

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A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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