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.
Initiate the facility’s restraint flow sheet.
Demonstrate proper securing of the restraints.
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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Correct Answer is ["B","E"]
Explanation
Choice A rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.
Choice B rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.
Choice C rationale
Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep
.
Choice D rationale
Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.
Choice E rationale
Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.
Correct Answer is A
Explanation
Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.
Choice C rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.
Choice D rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.