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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.
Choice B rationale
Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.
Choice C rationale
A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.
Choice D rationale
Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.
Choice E rationale
Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The correct answer is Constipation / Opioid use.
Constipation is a common side effect of opioid use. The client is receiving oxycodone for pain management, which can slow down the digestive system, leading to constipation.
Pressure injuries, also known as pressure ulcers or bedsores, are a risk due to prolonged immobility. This is especially relevant for a client who is postoperative and has limited movement. However, this was not selected as the primary condition based on the given clues.
Hypoglycemia (low blood sugar) is not directly indicated by the client's current medications or conditions. The client is receiving IV dextrose, but there is no indication of a risk of hypoglycemia in the provided information.
Confusion can occur in clients with cognitive impairments or due to medication side effects, but it is not specifically indicated as a primary risk in this case.
Dysrhythmias (abnormal heart rhythms) can be caused by imbalances in potassium or sodium levels, among other factors, but there is no evidence of such imbalances or related symptoms in this client’s case.
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