A charge nurse making rounds observes that an assistive personnel (AP) 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?

Inform the unit manager of the incident.

Speak with the AP about the incident.

Remove the restraints from the client's wrists.

Review the chart for nonrestraint alternatives for agitation,

Answer and Explanation

The Correct Answer is C

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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Correct Answer is D

Explanation

A. While involving the family might be beneficial for education, it's not directly related to assessing the client's needs for turning.
B. Assessing the client's pain level is important, but it's only one aspect of comprehensive care when delegating turning to the AP.
C. Checking the AP's availability for other tasks after turning the client is important but not the primary assessment before delegation.
D. Before delegating care, the nurse should assess and collect data about the client's specific needs related to turning due to the client's condition. Understanding the client's condition and requirements for turning is crucial for effective delegation.

A. A client who has gestational diabetes and is receiving biweekly nonstress tests B. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor C. A client who is at 32 weeks of gestation and has premature rupture of membranes D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump

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.

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A charge nurse making rounds observes that an assistive personnel (AP) 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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