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 A

Explanation

a. A client who has an asymmetrical thorax:

An asymmetrical thorax can indicate a potentially life-threatening condition such as a tension pneumothorax, hemothorax, or flail chest. These conditions can compromise respiratory function and require immediate intervention to ensure the client's airway and breathing are maintained.

b. A client who has an open fracture of the femur:

An open fracture of the femur is a serious injury that requires prompt attention to prevent complications such as infection and excessive blood loss. However, it is typically classified as urgent rather than emergent unless there are signs of significant hemorrhage or compromised perfusion that threaten life.

c. A client who has preorbital edema:

Preorbital edema, which is swelling around the eyes, can be concerning and requires evaluation but is not typically life-threatening. This condition is less likely to require immediate intervention compared to compromised airway or breathing issues.

d. A client who has a deep-partial thickness burn on the lower extremities:

Deep-partial thickness burns are serious and painful injuries that require medical attention. However, they are usually not immediately life-threatening unless they involve a large percentage of body surface area or are accompanied by other critical injuries or complications. They are often categorized as urgent rather than emergent.

A. A client who has Alzheimer’s disease and bacterial pneumonia with newly onset restlessness B. A client who is newly admitted with diabetes mellitus and whose fasting blood glucose level is 200 mg/dL C. A client who is 24 hr postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0 to 10 D. A client who is 3 days postoperative following abdominal surgery and is ready for discharge

Correct Answer is A

Explanation

a. A client with Alzheimer's disease and bacterial pneumonia with newly onset restlessness may be experiencing delirium, which could indicate a worsening of their pneumonia or another underlying issue. Delirium can be a sign of a serious medical condition and requires immediate assessment to determine the cause and provide appropriate intervention.

b. While a fasting blood glucose level of 200mg/dL in a newly admitted client with diabetes mellitus is high and requires attention, it is not as urgent as assessing a client with newly onset restlessness, as described in option a.

c. A client who is 24 hours postoperative following surgical reduction of a hip fracture and reports a pain level of 7 on a scale from 0-10 requires assessment and pain management, but it is not as urgent as assessing the client with newly onset restlessness.

d. A client who is 3 days postoperative following abdominal surgery and is ready for discharge may require routine assessment and preparation for discharge, but it is not as urgent as assessing the client with newly onset restlessness.

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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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