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 A
Explanation
a. Transcutaneous electrical nerve stimulation (TENS) is a form of physical therapy often used for pain management. Therefore, the physical therapist would be the appropriate member of the interdisciplinary team to contact for assistance with TENS.
b. Respiratory therapists primarily focus on respiratory care and would not typically be involved in assisting with TENS therapy.
c. Occupational therapists focus on helping clients perform activities of daily living and may not have specific expertise in managing TENS therapy.
d. While pharmacists are knowledgeable about medications, they may not have the expertise required to assist with TENS therapy, which is a form of physical therapy.
Correct Answer is A
Explanation
A. Closing the documentation program on the computer is the most immediate action to prevent further unauthorized access to protected health information (PHI). It directly addresses the breach of confidentiality and limits potential damage.
B. While it is important to identify the staff member responsible for leaving the program open, this does not immediately address the current breach of confidentiality. This action would be a subsequent step after securing the PHI.
C. Notifying the charge nurse is an important step in the process of addressing the breach. However, it is not the first action to take as it does not prevent further exposure of the PHI.
D. Informing the visitor about the confidentiality of client records is necessary, but it is not the first action to take. The priority is to secure the PHI before addressing the visitor's behavior.
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