The nurse is providing instructions to the nurse aide on how to accurately take an oral temperature. Which statement made by the nurse aide demonstrates correct understanding of the procedure?

Choice A reason: In a Just Culture, errors are addressed through accountability and learning rather than punishment. The nurse is expected to self-report the error, and the facility will likely provide education or training to prevent recurrence. This approach promotes transparency, safety, and continuous improvement.

Choice B reason: Saying nothing will happen because errors are expected is incorrect. While Just Culture recognizes that humans make mistakes, it does not ignore them. Errors must be reported and addressed to improve safety.

Choice C reason: Immediate firing and reporting to the Board of Nursing is punitive and not consistent with Just Culture. Unless the error was intentional or reckless, the nurse would not face such severe consequences.

Choice D reason: Restricting the nurse from administering medications for a period of time is not standard in Just Culture. The focus is on education and system improvement, not punishment or restriction unless competency is severely compromised.

Choice A reason: Removing restraints every 15 minutes is excessive and impractical. While frequent monitoring is required, removing restraints this often could compromise patient safety if the restraints are necessary to prevent harm. Toileting should be offered regularly, but the removal schedule must balance patient dignity with safety.

Choice B reason: Checking restraints every 2 hours is insufficient. Patients in restraints must be monitored much more frequently to ensure circulation, skin integrity, and safety. Two-hour intervals could allow complications such as impaired circulation, skin breakdown, or psychological distress to go unnoticed.

Choice C reason: Delegating safety checks to a UAP every hour is inappropriate because restraint monitoring requires licensed nursing judgment. LPNs must personally assess circulation, skin condition, and patient comfort. UAPs can assist with care but cannot replace the nurse’s responsibility for restraint monitoring.

Choice D reason: The correct action is to check the patient every 15 minutes and remove restraints every 2 hours if safe. This schedule ensures frequent monitoring for circulation, skin integrity, and psychological well-being, while also providing opportunities for mobility, toileting, and comfort. Removing restraints every 2 hours prevents complications and respects patient dignity, while frequent checks ensure safety.