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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. This statement demonstrates an understanding of the importance of protecting personal health information by encrypting it when transmitting electronically, ensuring confidentiality.
b. Using another nurse's password violates client confidentiality and compromises security protocols.
c. Discarding personal health information documents in the trash without proper disposal methods can lead to unauthorized access and breach of confidentiality.
d. Posting a client's vital signs in their room could potentially compromise their privacy, as it may be viewed by unauthorized individuals.
Correct Answer is D
Explanation
a. “You should contact the provider about your wishes for your family member”: While involving the provider is essential, it doesn’t directly address the conflicting wishes between the partner and the family member.
b. “You should speak with the facility’s ethics committee about your concerns”: While acknowledging the need for ethical guidance, this option may not be the most immediate step.
c. “We’ll need to have the nursing supervisor review the client’s advance directives”: Although reviewing advance directives is crucial, it doesn’t directly address the current disagreement.
d. “As the health care surrogate, the client’s partner can make this decision”: This response recognizes the legal authority of the health care surrogate (partner) to make decisions on behalf of the unconscious client. It aligns with established principles.
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