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 B

Explanation

A. Notifying risk management before initiating treatment is not necessary in this emergent situation; patient care should take precedence.
B. In emergent situations where a patient lacks decision-making capacity and requires
immediate treatment to prevent harm, consent for treatment can be assumed based on the principle of implied consent.
C. Contacting the client's next of kin for consent might delay necessary treatment for the disoriented and arrhythmic client, which could be harmful.
D. Having the client sign a consent for treatment might not be feasible or appropriate if the client is disoriented and lacks decision-making capacity in an emergency situation.

A. Two nurses had a heated disagreement about a scheduling issue. B. A client is refusing care from an assistive personnel of the opposite gender. C. Three staff members have called to say they will be absent. D. No transport assistance is available to take a client to physical therapy.

Correct Answer is C

Explanation

- A: While resolving conflicts is important to maintain a healthy work environment, it may not immediately affect patient care and safety.
- B: Client preferences should be respected, but this situation can usually be resolved by reassigning staff without immediate risk to patient safety.
- C: Staff absences can critically impact patient care due to inadequate staffing, which can lead to increased workload for present staff and compromise patient care.
- D: Transport issues, although they need to be addressed, do not usually pose an immediate threat to patient safety compared to inadequate staffing. Physical therapy can often be rescheduled without significant harm to the patient.

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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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