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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?

A.

Complete an adverse occurrence/incident report.

B.

Ensure that the restraints are not too tight.

C.

Initiate the facility’s restraint flow sheet.

D.

Demonstrate proper securing of the restraints.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Completing an adverse occurrence/incident report is important if an incident occurs, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

 

Choice B rationale

 

Ensuring that the restraints are not too tight is important for the client’s safety and comfort, but it does not address the improper securing of the restraints to the bedside rails. The restraints should be secured to a movable part of the bed frame, not the rails.

 

Choice C rationale

 

Initiating the facility’s restraint flow sheet is necessary for documentation, but it does not address the immediate issue of improper restraint application. The priority is to correct the UAP’s action to prevent potential harm to the client.

 

Choice D rationale

 

Demonstrating 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.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart, significantly reducing the risk of cardiovascular events and mortality.

Choice B rationale

A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While it helps in lowering cholesterol levels and reducing inflammation, smoking cessation has a stronger influence on overall cardiovascular health.

Choice C rationale

Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although managing stress can improve heart health, smoking cessation has a more immediate and significant impact on reducing cardiovascular risks.

Choice D rationale

Regular exercise is beneficial for preventing and managing cardiac disease, but it is not the most important lifestyle modification. Exercise helps in maintaining a healthy weight, lowering blood pressure, and improving overall cardiovascular health, but smoking cessation has a greater impact on reducing the risk of cardiovascular events.

Correct Answer is C

Explanation

Choice A rationale

Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.

Choice B rationale

Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

Choice C rationale

Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.

Choice D rationale

Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

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