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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A.Documenting the time of the error is important for accurately recording when the event happened and for assessing potential impacts on patient care.
B.Including specific details about the medication involved and the dosage is crucial for understanding the nature of the error and for evaluating its potential consequences.
C.Incident reports are confidential and should not be copied for personal records. They are used for internal review and quality improvement purposes and should be handled according to the facility's policies on confidentiality.
D.The incident report should not be placed in the client’s medical record. It is a separate document intended for internal use and quality improvement, not part of the client’s clinical record.
E.No order from the provider is needed to complete an incident report. The report is a standard procedure for documenting and analyzing errors and is part of the facility's protocol for ensuring patient safety.
Correct Answer is A
Explanation
a. "I will wear a surgical mask within 3ft of the client":
This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.
b. "I will check that the room has a high-efficiency particulate air filtration system":
This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.
c. "I will wear an N95 respirator when providing care for the client":
This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.
d. "I will assign the client to a room with positive airflow":
This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.
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