An unlicensed assistive personnel (UAP) is asked to answer the call light for a client with streptococcal pharyngitis for whom droplet precautions have been implemented. The UAP refuses, informing the nurse of not being fitted for an N95 respirator mask. Which action should the nurse take?

Choice A reason: Reinserting the PIV catheter restores IV access but is not the immediate priority. Ensuring restraints can be quickly released addresses safety, as delayed removal risks injury during emergencies. Restraint safety, mandated by regulatory standards, takes precedence to protect the client before addressing therapeutic devices like IVs.

Choice B reason: Verifying that restraints can be quickly released ensures client safety, as per Joint Commission standards. Rapid release is critical in emergencies, like choking or fire, to prevent harm. This action prioritizes client protection, ensuring restraints do not impede evacuation or intervention, making it the most immediate post-application step.

Choice C reason: Assessing capillary refill monitors circulation distal to restraints, which is important but secondary to ensuring quick release. Rapid release prevents harm in emergencies, a higher safety priority. Circulation checks are part of ongoing monitoring, but immediate restraint safety takes precedence to comply with regulatory and ethical standards.

Choice D reason: Replacing the NGT restores its function but is not the first priority after applying restraints. Ensuring quick release prevents entrapment or injury in emergencies, a critical safety concern. NGT replacement can follow once restraint safety is confirmed, as client protection from restraint-related risks is paramount.

Choice A reason: Residual urine of 150 ml indicates incomplete bladder emptying, increasing the risk for urinary tract infections. Stagnant urine fosters bacterial growth, especially with volumes exceeding 100 ml. This nursing problem prioritizes monitoring and interventions like catheterization or bladder training to prevent infection, aligning with evidence-based urological care principles.

Choice B reason: Deficient fluid volume is unrelated to 150 ml residual urine, which reflects retention, not dehydration. Residual urine suggests bladder dysfunction, not fluid loss. This nursing problem is inappropriate, as the issue is urinary stasis, which predisposes to infection rather than indicating a systemic fluid deficit.

Choice C reason: Urinary incontinence involves involuntary urine leakage, not retention. Residual urine of 150 ml indicates the bladder is not emptying fully, suggesting retention rather than incontinence. This nursing problem is incorrect, as the client’s issue is incomplete voiding, which requires different interventions focused on bladder function.

Choice D reason: Imbalanced nutrition is unrelated to residual urine, which is a urological issue. Residual urine reflects bladder dysfunction, not dietary or metabolic problems. This nursing problem is irrelevant, as the priority is addressing urinary retention to prevent complications like infection, not nutritional status.