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 A
Explanation
A. Battery involves unauthorized or harmful physical contact, which administering the injection without consent would constitute.
B. False imprisonment involves restricting a person's freedom of movement unlawfully, which doesn't apply in this scenario.
C. Assault involves the threat of unwanted or harmful contact.
D. Libel refers to written defamation or false statements that damage someone's reputation, which is not relevant in this situation involving administering medication.
Correct Answer is B
Explanation
A. Waiting to dispose of sharps containers until they are completely full might compromise safety and infection control practices.
B. Using clean gloves rather than sterile gloves for colostomy care is a possible interventin that can be applied.
C. Returning unused supplies to the unit's supply stock is not correct.
D. Storing opened bottles of normal saline for up to 48 hours might not be compliant with storage guidelines and could risk contamination, potentially increasing costs through wastage or patient harm.
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