A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Apply the restraint under the client's clothes.

Tie the restraint to the railing of the client's bed.

Place the client in a sitting position.

Ensure the restraint is placed across the client's chest.

Answer and Explanation

The Correct Answer is C

a. Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.

b. Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.

c. Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.

d. A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.

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Correct Answer is B

Explanation

When a central venous catheter (CVC) is inserted, it is essential to confirm proper catheter placement to ensure safe and effective administration of TPN and other medications. A chest x-ray is the gold standard method to verify the correct positioning of the CVC tip. It helps determine if the catheter is appropriately positioned in the superior vena cava or another desired location, which minimizes the risk of complications such as pneumothorax or improper medication delivery.

The other options listed are not appropriate actions for the nurse to take in this situation:

Verifying the amount of TPN solution the client is receiving every 4 hours is a task related to ongoing monitoring of TPN administration, but it is not directly related to the preparation of the client for CVC insertion.
Using clean technique when changing the catheter dressing is not appropriate for CVC insertion. Sterile technique is required during the insertion of a CVC to minimize the risk of infection.
Placing the client in Sims' position is not the appropriate position for CVC insertion. The client is typically placed in a supine or Trendelenburg position during the procedure to facilitate access to the central venous system.

A. Case manager B. Nutritionist C. Primary care provider D. Pediatric nurse practitioner

Correct Answer is A

Explanation

A case manager is a member of the interprofessional team who specializes in coordinating and facilitating access to healthcare services and resources for individuals and families. They can assist the client in identifying and accessing financial assistance programs or resources that can help with the cost of baby formula.

Case managers have knowledge of community resources and can provide guidance and support in navigating the system to meet the client's needs. While a nutritionist may provide guidance on infant nutrition, they may not have direct access to financial assistance programs or resources. The primary care provider and pediatric nurse practitioner may be involved in the client's care but may not have the specific expertise in addressing financial concerns.

Therefore, referring the client to a case manager is the most appropriate action in this situation.

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A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

Nursing Test Bank

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