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. Pharmacist: While a pharmacist may assist with medication-related concerns, they may not be able to address broader financial issues or access to resources.
b. Child protective services: Child protective services are not relevant in this scenario as there is no indication of child neglect or abuse.
c. Social worker: Social workers are trained to assist individuals and families with various social and financial issues, including accessing resources for medical needs.
d. Respiratory therapist: While a respiratory therapist may provide education and support related to asthma management, they may not be able to address the parent's financial concerns directly.

A. Root cause analysis B. Benchmarking C. Risk benefit analysis D. Structure audit

Correct Answer is B

Explanation

a. Root cause analysis: Root cause analysis is used to investigate the underlying causes of errors or adverse events, rather than comparing performance metrics between different units or organizations.
b. Benchmarking: Benchmarking involves comparing performance metrics, such as medication error rates, against those of other similar units or organizations to identify areas for improvement and best practices.
c. Risk benefit analysis: Risk benefit analysis involves weighing the potential risks and benefits of a particular course of action, such as a medical intervention, to make informed decisions. It is not directly related to comparing performance metrics.
d. Structure audit: Structure audit involves assessing the physical or organizational aspects of healthcare delivery, such as the availability of resources or adherence to protocols, which is not specifically addressed in the scenario.

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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

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