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 B
Explanation
a. While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b. Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c. Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d. Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.
Correct Answer is B
Explanation
a. This is incorrect because a health care proxy doesn't necessarily have to be a family member. It can be any person chosen by the individual.
b. This is the correct response because it accurately describes the role of a health care proxy, which is to make decisions for the individual when they are unable to do so themselves.
c. This is incorrect because appointing a health care proxy is not contingent upon undergoing an invasive procedure.
d. This is incorrect because the involvement of an attorney is not necessary to appoint a health care proxy.
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