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. Help the AP assist the client with the transfer.

While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.

b. Demonstrate the proper client transfer technique to the AP.

Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.

c. Instruct the AP to request assistance when unsure about a task.

Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.

d. Refer the AP to the facility procedure manual.

Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.

A. Is the client’s family present so the AP can show them how to turn the client? B. Does the AP have time to change the client’s central IV line dressing after turning her? C. Has data been collected about specific client needs related to turning? D. Has the AP checked the client’s pain level prior to turning her?

Correct Answer is C

Explanation

a. Is the client’s family present so the AP can show them how to turn the client:

While involving the client's family in care can be beneficial for education and support, this assessment does not directly pertain to the AP's ability to provide care or the client's immediate needs.

b. Does the AP have time to change the client’s central IV-line dressing after turning her:

This assessment is relevant to the AP's workload and scheduling, but it does not directly address the client's care needs related to bathing and turning.

c. Has data been collected about specific client needs related to turning:

This assessment is crucial before delegating care. The nurse should ensure that relevant information about the client's condition, including any specific needs or considerations related to turning, has been gathered and communicated to the AP to provide appropriate care.

d. Has the AP checked the client’s pain level prior to turning her:

This assessment is essential to ensure the client's comfort and safety during care activities. Assessing the client's pain level before turning helps prevent exacerbation of pain and ensures that turning is performed with appropriate consideration for the client's comfort.

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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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