A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?
Using a quick-release tie to secure the restraint.
Tying the restraint to the bed frame.
Placing the restraint across the client's chest.
Applying the restraint over the client's gown.
The Correct Answer is C
Choice A rationale
Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.
Choice B rationale
Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.
Choice C rationale
Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.
Choice D rationale
Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing the client's arms above her head prior to logrolling can cause discomfort and injury, especially after spinal surgery. Arms should be kept at the sides to maintain alignment.
Choice B rationale
Placing the client in semi-Fowler's position before logrolling is incorrect. The semi-Fowler's position is not stable for logrolling and does not align the spine correctly for safe movement.
Choice C rationale
Placing the bed in the lowest position before logrolling can make the process more difficult and unsafe. The bed should be at a height that allows proper body mechanics for the caregiver.
Choice D rationale
Placing a pillow between the client's legs prior to logrolling helps maintain spinal alignment and prevents twisting of the spine, which is crucial after a laminectomy.
Correct Answer is C
Explanation
Choice A rationale
Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.
Choice B rationale
Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.
Choice C rationale
Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.
Choice D rationale
Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.
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