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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Related Questions
Correct Answer is B
Explanation
A. Accompanying a client to physical therapy is a task that can be appropriately delegated to an AP, as it does not require clinical judgment or advanced nursing knowledge. This task does not require the skills of an LPN.
B. Reinforcing dietary teaching with a client who has heart disease is within the scope of practice for an LPN. LPNs can reinforce teaching that has already been initiated by the registered nurse (RN). This task involves some level of knowledge and skill but does not require independent clinical judgment, making it suitable for the LPN.
C. Obtaining a urine specimen from an older adult client is a task that can be delegated to an AP, as it is a routine procedure that does not require nursing assessment or decision-making. This task does not require the skills of an LPN.
D. Providing postmortem care for a client who has just died is a task that can be appropriately delegated to an AP. This task involves following established protocols and does not require clinical judgment or advanced nursing skills. It is not necessary to assign this task to an LPN.
Correct Answer is A
Explanation
A. A physical therapist can assist with the proper application and usage of transcutaneous electrical nerve stimulation (TENS) for pain management, providing guidance on its use and techniques for optimal outcomes.
B. Occupational therapists focus more on functional activities related to daily living.
C. Respiratory therapists specialize in respiratory care.
D. Pharmacists primarily handle medication-related concerns and may not specifically assist with TENS therapy.
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