The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Complete an adverse occurrence/incident report.

Ensure that the restraints are not too tight.

Demonstrate proper securing of the restraints.

Initiate the facility’s restraint flow sheet.

Answer and Explanation

The Correct Answer is C

Choice A: Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client. The nurse should report the incident after ensuring the safety and comfort of the client.
Choice B: Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
Choice C: Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.
Choice D: Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because lifting and locking the side rails in place is a standard safety measure for all clients, but it does not address the specific risk of respiratory depression caused by morphine and OSA.

Choice B Reason: This is correct because applying the client's positive airway pressure device can help maintain airway patency and prevent hypoxia and hypercapnia, which are common complications of OSA and opioid use.

Choice C Reason: This is incorrect because elevating the head of the bed to a 45-degree angle can help reduce chest pain and dyspnea, but it does not prevent airway obstruction or respiratory depression.

Choice D Reason: This is incorrect because removing dentures or other oral appliances can help prevent aspiration, but it does not affect the client's breathing pattern or oxygenation.

A. Remind the UAP to dry between the client’s toes completely. B. Advise the UAP that this procedure is damaging to the skin. C. Add skin cream to the basin of water while the foot is soaking. D. Remove the basin of water from the client’s bed immediately.

Correct Answer is D

Explanation

Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.

Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.

Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.

Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.

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The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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