A charge nurse making rounds observes that 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

Speak with the AP about the incident

Remove the restraints from the client’s wrist

Answer and Explanation

The Correct Answer is D

a.   Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b.   Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c.   Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d.   Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

- A: Night sweats and fever could indicate an infection or a chronic condition, which, while important, may not require immediate attention compared to life-threatening conditions.
- B: Compound fractures are serious and require medical attention, but they are not immediately life-threatening if the patient is stable.
- C: Severe vomiting and diarrhea can lead to dehydration and electrolyte imbalance, which are concerning but can be managed with prompt treatment and do not typically pose an immediate threat to life.
- D: Soot markings around the naris indicate possible inhalation injury from a fire, which is a critical condition that can rapidly worsen and lead to airway compromise, making it the highest priority for immediate assessment and intervention.

A. Instruct the client’s family to contact the insurance provider about the oxygen equipment B. Send an oxygen tank from the facility home with the client C. Contact social services about the delivery of the oxygen equipment D. Notify the provider about the delayed oxygen tank delivery

Correct Answer is D

Explanation

a. Instructing the client's family to contact the insurance provider may be appropriate for resolving insurance-related issues but does not directly address the delay in oxygen tank delivery.
b. Sending an oxygen tank from the facility home with the client may not be feasible or within the nurse's scope of practice without coordination with the equipment provider.
c. Contacting social services may not be necessary for resolving the delayed delivery of oxygen equipment, as this is typically managed by the equipment provider or the client's healthcare team.
d. Notifying the provider about the delayed oxygen tank delivery allows for appropriate follow-up and coordination to ensure the client receives the necessary equipment in a timely manner.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A charge nurse making rounds observes that 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

Correct Answer is D

Explanation

A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has been admitted and diagnosed with type 1 diabetes mellitus. The client tells the nurse she has decided to go home. Which of the following actions should the nurse take?

A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

29A nurse is preparing an educational program for staff members 2 a new intravenous pump. Identify the sequence of actions the nurse should take when developing the program. (Move the steps into the box on the right, placing them in order of performance).

A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the Inservice?

A nurse on a medical-surgical unit is evaluating an assistive personnel’s (AP) use of infection control precautions. Which of the following actions by the AP indicates correct use of the precautions?

A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client's care?

A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?