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,
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone not
involved in direct care.
C. Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.
Correct Answer is D
Explanation
A. Reviewing facility policies is important but might not immediately address the reasons why the nurses are not taking breaks.
B. Discussing time management strategies might be helpful, but it's crucial to first understand the reasons behind the nurses' behavior.
C. Providing coverage for the nurses' breaks might be a short-term solution but doesn't address the underlying reasons for not taking breaks.
D. Determining the reasons the nurses are not taking scheduled breaks is the initial step to understand if it's due to workload, personal choice, or other factors. This information can guide appropriate interventions or support for the nurses.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.