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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: The autonomy of the patient is paramount in medical ethics. If the client understands the risks and still refuses the procedure, their choice must be respected. It is a fundamental right for patients to make informed decisions about their own healthcare.
B: While a durable power of attorney for health care is crucial when a patient is incapacitated, it does not override the wishes of a competent patient. As long as the client is capable of making decisions, their consent is required for any procedure.
C: Although religious beliefs are respected, they do not serve as the primary deciding factor if the client is competent. The client's understanding and decision-making capacity are the key determinants in whether to proceed with the surgery.
D: The ethics committee can provide guidance on complex cases, but it cannot make decisions for a competent patient. The committee's role is advisory, and the final decision rests with the patient.
Correct Answer is C
Explanation
a. While documenting that an incident report has been filed is important, it should not be the first action taken. The nurse should first take steps to address the issue.
b. In this situation, contacting risk management may be necessary, but the immediate priority should be to address the client's concerns and ensure appropriate follow-up.
c. Contacting the nurse manager is the appropriate first action to report the client's complaint and initiate further investigation and intervention as needed.
d. Reassuring the client about the staff's training is not sufficient in addressing the client's complaint of excessive force. The issue should be reported to the appropriate authority for investigation and resolution.
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