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?

a. The AP wears a surgical mask when caring for a client who has respiratory tuberculosis.

Incorrect. AP should wear an N95 Maskwhen caring for a client with respiratory tuberculosis helps prevent the spread of airborne pathogens, protecting both the healthcare worker and others in the environment.

b. The AP uses alcohol-based hand sanitizer after emptying the bedpan of a client who has Clostridium difficile.

This action is incorrect. Alcohol-based hand sanitizers are not effective against the spores of Clostridium difficile. Handwashing with soap and water is necessary to effectively remove the spores.

c. The AP bundles the client side of linen inward when changing the sheets for a client who has an infected surgical wound.

When handling soiled linen, it is essential to fold the client side of the linen inward to minimize the spread of contaminants. This helps to ensure that any contaminated surfaces do not come into contact with other surfaces, which is crucial for preventing the spread of infection.

d. The AP removes her gloves before leaving the room of a client who has MRSA.

For MRSA (Methicillin-resistant Staphylococcus aureus), the AP should remove gloves and perform hand hygiene before leaving the room.

a. "I should encrypt personal health information when sending emails."

This statement indicates an understanding of the importance of protecting confidential information during electronic communication. Encrypting personal health information in emails adds an extra layer of security to prevent unauthorized access.

b. "I can use another nurse’s password as long as I log off after using the computer."

This statement is incorrect and demonstrates a lack of understanding of client confidentiality. Sharing passwords is a violation of security policies and compromises the confidentiality of client information. Each nurse should have their unique login credentials to ensure accountability and traceability.

c. "I should discard personal health information documents in the trash before leaving the unit."

This statement is incorrect. Discarding personal health information in an unsecured manner, such as in the regular trash, can lead to unauthorized access and a breach of confidentiality. Proper disposal methods, such as shredding or using secure disposal containers, should be followed to protect sensitive information.

d. "I can post the client’s vital signs in the client’s room."

This statement is incorrect. Posting client information, including vital signs, in a public area like the client's room violates confidentiality. Personal health information should be shared only with authorized individuals involved in the patient's care and through secure communication methods. Posting such information in a public space compromises the client's privacy.