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. A client receiving an operation on the wrong side of the body is a serious medical error but might not inherently involve an ethical dilemma unless the decision-making process and accountability are in question.
B. A parent wanting a 14-year-old adolescent to receive radiation treatment against his will involves conflicting values of autonomy, beneficence, and parental rights,
constituting an ethical dilemma.
C. A visitor experiencing a minor burn is an incident but doesn't inherently pose an ethical dilemma.
D. A nurse witnessing another nurse administering an incorrect medication is a patient safety issue but might not inherently involve an ethical dilemma unless there are questions about reporting or intervening in the situation.
Correct Answer is A
Explanation
A. Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B. Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C. Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D. Filing an incident report might be necessary but should follow an assessment and investigation of the situation.
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