A nurse is delegating oral care for a client who is unconscious to an assistive personnel (AP). The AP tells the nurse that APs are not allowed to perform the delegated task. Which of the following actions should the nurse take?

A. While notifying the risk manager might be appropriate if there is an ongoing pattern of safety concerns or systemic issues, it is not the most immediate or direct way to address the immediate concern of the nurse's inability to safely care for clients in an unfamiliar unit.
B. The charge nurse has the authority to modify assignments and can reassign clients or adjust responsibilities based on the nurse's experience and competency. By communicating the concern to the charge nurse, the newly licensed nurse can ensure that clients receive safe and effective care, and the charge nurse can make adjustments to better align the assignment with the nurse's experience level.
C. Documenting the concern in the nurse's notes is important for record-keeping but does not address the immediate need for reassignment or adjustments. Documentation is useful for future reference or to support any formal complaints or reviews but does not solve the current issue of inadequate experience for the assigned tasks.
D. Accepting the assignment while relying on assistive personnel may compromise patient safety if the nurse does not have the necessary experience. Although assistive personnel can provide support, they cannot substitute for the nurse's clinical judgment and skills.

A. Restraints should not be attached to the bed frame. Instead, they should be secured to a movable part of the bed (such as side rails) to prevent injury. Attaching restraints to the bed frame can cause harm to the patient and limit their mobility.
B. While it's essential to assess and reposition restraints regularly, removing them entirely every 2 hours is not recommended unless the patient's condition allows for it. Restraints should be removed and repositioned at least every 2 hours to assess skin integrity, circulation, and comfort. However, they should not be removed entirely unless necessary.
C. Square knots are not recommended for restraining patients because they can be difficult to untie quickly in case of an emergency. Quick-release buckles or Velcro fasteners are safer options.
D. Allowing 1 fingerbreadth between the restraint and the client's wrists ensures proper circulation and prevents excessive tightness. Properly fitting restraints prevent injury while maintaining patient safety.