Difficulty: Medium
Average Score: 71%
Simulated
A charge nurse making rounds observes that assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
Correct answer
D
Rationale
Removing unauthorized restraints ensures immediate safety. Reviewing alternatives , informing the manager , or speaking with the AP follow after addressing the client's safety.