Question

The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?

Answer 1

The nurse should check that all procedural matters, such as correct labeling of the specimen and completion of the count of needles, sponges, and instruments, are in order and address any equipment issues. Additionally, they should review recovery and care concerns with the relevant healthcare team.

Step-by-step explanation:

When a nurse enters a client's room and observes the client's wrist restraint secured, several key actions should be taken. The nurse should ensure that restraints are used only when necessary and that the patient's rights and well-being are protected. Proper procedure requires verifying that:

• The name of the procedure is correctly recorded.
• Needle, sponge, and instrument counts are complete, or if not applicable, that is noted.
• Any examined specimen is correctly labeled, including with the patient's name.
• There are no issues with equipment that need to be addressed.

In addition, it is critical that the surgeon, nurse, and anesthesia professional collaboratively review the key concerns for the patient's recovery and care after the procedure. This attention to detail ensures patient safety and adherence to health care protocols.