A charge nurse making rounds observes that 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

Speak with the AP about the incident

Remove the restraints from the client’s wrist

Answer and Explanation

The Correct Answer is D

a.   Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b.   Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c.   Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d.   Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

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Correct Answer is C

Explanation

a. Delaying the client's discharge without exploring other options may not address the partner's concerns and could lead to further issues.
b. While placing the client in a long-term care facility may be an option, it should be discussed with the case manager and considered alongside other options.
c. Contacting the case manager is appropriate to discuss the partner's concerns and explore alternative discharge arrangements that meet the client's needs.
d. Requesting another family member to assist may not be feasible or address the partner's ability to provide care.

A. A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness B. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 D. A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Correct Answer is A

Explanation

a. The client with Alzheimer's disease and bacterial pneumonia experiencing newly onset restlessness may indicate a change in their condition, such as worsening infection or delirium, which requires immediate assessment and intervention to address their underlying medical needs.
b. While hyperglycemia in a newly admitted client with diabetes mellitus is concerning, it does not typically require immediate assessment unless accompanied by signs of diabetic ketoacidosis or other acute complications.
c. Although the client postoperative from hip fracture reduction reporting a pain level of 7 requires attention, it is not as urgent as assessing the client with newly onset restlessness, which may indicate a more acute issue.
d. The client who is 3 days postoperative and ready for discharge does not require immediate assessment compared to the client with newly onset restlessness, whose condition may be deteriorating.

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A charge nurse making rounds observes that 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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