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    Hesi rn med surg proctored exam

    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?

    Explanation & Rationale

    A. Complete an adverse occurrence/incident report may be necessary if harm occurs, but the priority is to immediately correct the unsafe practice to prevent injury. B. Ensure that the restraints are not too tight is important, but addressing the incorrect technique of securing restraints to the bedside rails takes precedence as it poses a greater risk to the client’s safety. C. Initiate the facility's restraint flow sheet is part of documentation but does not address the immediate safety concern. D. Demonstrate proper securing of the restraints is correct because restraints should never be secured to movable parts of the bed, such as the rails, as this can cause injury. The nurse must provide immediate education to the UAP to prevent harm and ensure the restraints are applied correctly.

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