The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her
wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?
Contact the healthcare provider to ensure that a prescription for restraints was written.
Advise the staff nurse to remove the restraints from the client's wrists.
Close the door to the room to avoid disturbing other clients in nearby rooms.
Determine if the client has an as needed (PRN) prescription for an antianxiety agent
Determine if the client has an as needed (PRN) prescription for an antianxiety agent
The Correct Answer is B
Choice A Reason: Contacting the healthcare provider is not the priority action because restraints should only be used as a last resort and not for staff convenience. The nurse manager should first ensure that the client's safety and dignity are respected.
Choice B Reason: This is the correct answer because restraints are not indicated for this situation and violate the client's rights. The nurse manager should educate the staff nurse about the ethical and legal implications of using restraints without proper justification and documentation.
Choice C Reason: Closing the door to the room is not a priority action because it does not address the issue of restraints. It also may isolate the client and increase her anxiety and distress.
Choice D Reason: Determining if the client has a PRN prescription for an antianxiety agent is not a priority action because it does not address the issue of restraints. It also may not be appropriate to medicate the client without assessing her condition and obtaining her consent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.
Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.
Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.
Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.
Correct Answer is A
Explanation
Choice A Reason: The nurse's first responsibility is to assess the underlying cause of the refusal. Since fluid volume overload is a critical condition, understanding whether the refusal is due to pain, fatigue, or a lack of understanding allows the nurse to provide appropriate education or interventions to ensure compliance with the plan of care.
Choice B Reason:Instructing the UAP to use a bed scale ignores the client's right to refuse and fails to address the initial conflict. Forcing a weight measurement without assessment can damage the nurse-client relationship. The nurse must first determine if the client is physically unable to stand or simply unwilling to participate.
Choice C Reason: Directing the UAP to delay weighing the client until later is not an appropriate action because it may result in missing or inaccurate data. The nurse should ensure that the client is weighed at the same time every day, preferably in the morning, before any fluid intake or output.
Choice D Reason: Documenting that the client refused daily weights is not an adequate action because it does not reflect the nurse's responsibility to provide quality care for the client. The nurse should try to resolve the issue of weighing the client and documenting the outcome and any interventions.
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