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. While reviewing current literature is an important step in the quality improvement process, it should not be the first action taken after problem identification.
b. Implementing a fall prevention plan is an important step but should be based on a thorough assessment of clients at risk for falls, which should be done first.
c. Identifying clients who are at risk for falls is the first step in addressing the issue of increased falls, as it allows for targeted interventions and prevention strategies.
d. Notifying staff of the increased fall rate may be necessary but should not be the first action taken. Identifying clients at risk for falls should be prioritized to implement preventive measures.

A. “I will wear a surgical mask within 3ft of the client” B. “I will check that the room has a high-efficiency particulate air filtration system” C. “I will wear an N95 respirator when providing care for the client” D. “I will assign the client to a room with positive airflow”

Correct Answer is A

Explanation

Rationale:
a. Droplet precautions require healthcare workers to wear a surgical mask when within 3 feet of the client to prevent the transmission of respiratory droplets containing infectious agents like influenza.
b. While high-efficiency particulate air (HEPA) filtration systems can help improve air quality, they are not specifically required for implementing droplet precautions.
c. N95 respirators are typically reserved for airborne precautions, which are not indicated for influenza.
d. Assigning the client to a room with positive airflow is not necessary for implementing droplet precautions; standard precautions such as wearing a surgical mask are sufficient.

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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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