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 D

Explanation

- A: Night sweats and fever could indicate an infection or a chronic condition, which, while important, may not require immediate attention compared to life-threatening conditions.
- B: Compound fractures are serious and require medical attention, but they are not immediately life-threatening if the patient is stable.
- C: Severe vomiting and diarrhea can lead to dehydration and electrolyte imbalance, which are concerning but can be managed with prompt treatment and do not typically pose an immediate threat to life.
- D: Soot markings around the naris indicate possible inhalation injury from a fire, which is a critical condition that can rapidly worsen and lead to airway compromise, making it the highest priority for immediate assessment and intervention.

A. A client who has type 1 diabetes and uses an insulin pump B. A client who is receiving heparin and has an aPTT of 34 seconds C. A client who has orthostatic hypotension and is receiving IV fluids D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dl

Correct Answer is D

Explanation

a. While a client with type 1 diabetes using an insulin pump may require interdisciplinary collaboration for optimal management, this scenario does not suggest an immediate need for an interdisciplinary conference.
b. A client receiving heparin with an aPTT of 34 seconds may require adjustment of the heparin dosage, but this situation does not necessitate an interdisciplinary conference.
c. A client with orthostatic hypotension receiving IV fluids may require close monitoring and collaboration among healthcare providers, but this situation does not suggest an immediate need for an interdisciplinary conference.
d. A client at risk for pressure ulcers with an albumin level of 4.2 g/dl may require an interdisciplinary conference to address nutrition, wound care, and preventive measures to reduce the risk of pressure ulcer development.

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