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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Instructing the AP to request assistance when unsure about a task is important for future situations, but it does not immediately address the current incorrect transfer, which could pose a risk to the client.
B. Demonstrating the proper client transfer technique for the AP directly addresses the immediate issue, ensuring the client is safely transferred and the AP learns the correct method through observation and practice.
C. Helping the AP assist the client with the transfer ensures the client's safety in the moment, but it does not provide the AP with the knowledge or skills needed to perform the task correctly in the future.
D. Referring the AP to the facility procedure manual is useful for long-term learning, but it does not provide the immediate guidance needed to correct the current unsafe transfer.

A. Find out which staff member left the documentation program on the screen B. Tell the charge nurse that a visitor viewed a client's protected health information C. Inform the visitor that client records are confidential. D. Close the computer program

Correct Answer is D

Explanation

Choice A Rationale: While it is important to identify the staff member responsible for leaving sensitive information accessible, it is not the first action that should be taken. The immediate risk of a confidentiality breach must be addressed before investigating the cause.
Choice B Rationale: Notifying the charge nurse is a necessary step, but it is not the most immediate action required. The priority is to secure the confidentiality of the client's information.
Choice C Rationale: Informing the visitor about the confidentiality of records is crucial, but the first action should be to prevent further viewing of the information.
Choice D Rationale: Closing the computer program is the first and most direct action to secure the client's medical information and prevent any further unauthorized access. This action immediately addresses the privacy breach and protects the client's confidential information.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse enters the hallway and discovers a visitor looking at a client's medical information on a computer. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?

A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take?

A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?

A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?