The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bedside rails. Which action is most important for the nurse to implement?
Complete an adverse occurrence/incident report.
Ensure that the restraints are not too tight.
Demonstrate proper securing of the restraints.
Initiate the facility’s restraint flow sheet.
The Correct Answer is C
Choice A: Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client. The nurse should report the incident after ensuring the safety and comfort of the client.
Choice B: Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
Choice C: Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment. The nurse should show the UAP how to secure the restraints to a movable part of the bed frame, not to the rails.
Choice D: Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because regular exercise is a beneficial lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a greater impact on reducing the risk of cardiovascular events and mortality.
Choice B Reason: This is incorrect because stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a more direct effect on improving the function and structure of the blood vessels and heart.
Choice C Reason: This is correct because smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease, as smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction.
Choice D Reason: This is incorrect because a low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a stronger influence on lowering the levels of cholesterol and inflammation in the blood.
Correct Answer is A
Explanation
Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.
Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.
Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.
Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.
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