A charge nurse making rounds observes that an assistive personnel 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?

Review the chart for nonrestraint alternatives for agitation

Inform the unit manager of the incident

Speak with the AP about the incident

Remove the restraints from the client’s wrists

Answer and Explanation

The Correct Answer is D

a. Review the chart for nonrestraint alternatives for agitation:

This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.

b. Inform the unit manager:

Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.

c. Speak with the AP about the incident:

Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.

d. Remove the restraints from the client’s wrist:

In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.

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Correct Answer is C

Explanation

a. "You can ask an AP to teach a simple task to a client."

While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.

b. "You should assign tasks you are unfamiliar with to an experienced AP."

Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.

c. "If you are unsure about an AP’s ability, observe them performing the task."

This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.

d. "The person who delegates a task is not held accountable for the outcome."

This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.

A. Prepare to administer antibiotics to the client B. Wear an N95 respirator mask while caring for the client C. Plan to administer an antiviral medication to the client D. Place a surgical mask on the client during transfer to the unit

Correct Answer is A

Explanation

a. Prepare to administer antibiotics to the client.

This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.

b. Wear an N95 respirator mask while caring for the client.

While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.

c. Plan to administer an antiviral medication to the client.

Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.

d. Place a surgical mask on the client during transfer to the unit.

Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.

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A charge nurse making rounds observes that an assistive personnel 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?

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