A charge nurse making rounds observes that an assistive personnel 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?

Review the chart for nonrestraint alternatives for agitation

Inform the unit manager of the incident

Speak with the AP about the incident

Remove the restraints from the client’s wrists

Answer and Explanation

The Correct Answer is D

a. Review the chart for nonrestraint alternatives for agitation:

This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.

b. Inform the unit manager:

Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.

c. Speak with the AP about the incident:

Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.

d. Remove the restraints from the client’s wrist:

In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.

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Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

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A charge nurse making rounds observes that an assistive personnel 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?

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