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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse is teaching a newly licensed nurse about client confidentiality. The nurse should include which of the following examples represents a violation of client confidentiality?
a. Calling the pharmacy with a prescription for the client's partner to pick up
b. Informing housekeeping staff that the client is in the dialysis unit
c. Reporting a client's disposition to the referring provider
d. Providing a copy of the client's medical record to the transporting paramedic
Correct Answer is C
Explanation
54) A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to experienced assistive personnel. Which of the following assessments should the nurse make before delegating care?
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?
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