A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?
Contact the nurse manager.
Call risk management to interview the client.
Reassure the client that the staff is well trained.
Document in the client's chart that an incident report has been filed.
The Correct Answer is A
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
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Related Questions
Correct Answer is D
Explanation
A. A client with gestational diabetes receiving biweekly nonstress tests typically requires monitoring and assessment that align more closely with obstetric nursing knowledge and skills rather than medical-surgical nursing.
B. A multigravida client with preeclampsia receiving misoprostol for induction of labor needs specialized obstetric care due to the complexity of the condition and the induction process.
C. A client at 32 weeks of gestation with premature rupture of membranes would require obstetric care expertise for monitoring and management.
D. A primigravida client 1 day postoperative following a Cesarean section with a patient- controlled analgesia (PCA) pump requires specialized postoperative obstetric care,
making this assignment suitable for the RN who floated from a medical-surgical unit due to their experience with postoperative care and pain management.
Correct Answer is C
Explanation
A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
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