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,
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Management of Type 1 diabetes with an insulin pump usually involves ongoing monitoring and adjustments but may not necessarily warrant an immediate interdisciplinary conference.
B. This client has a notable risk for pressure ulcers due to the albumin level, necessitating an interdisciplinary approach to prevent or manage these ulcers.
C. While monitoring heparin therapy is crucial, an aPTT of 34 seconds is within the therapeutic range and may not require an urgent interdisciplinary conference.
D. Orthostatic hypotension being managed with IV fluids may need ongoing assessment, but it may not warrant an immediate interdisciplinary conference.
Correct Answer is C
Explanation
A. Inadequate food supply is important but might not be the most immediate concern following coronary artery bypass grafting surgery.
B. Limited social support is significant for the client's recovery but might not directly impact the immediate post-operative care.
C. Low pain tolerance after a major surgery like coronary artery bypass grafting can impede recovery, affect mobility, and hinder the client's ability to participate in rehabilitation exercises or manage post-operative pain effectively. Addressing pain
tolerance is crucial for post-operative recovery.
D. Decreased self-esteem, while important for the client's overall well-being, might not be an immediate priority in the early stages following surgery compared to managing physical recovery and pain tolerance.
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