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
Explanation
Choice A rationale
"Tell me more about what happens at mealtime.”. This response encourages the caregiver to share detailed information about mealtime routines and behaviors, which can help the nurse identify underlying issues and suggest appropriate strategies.
Choice B rationale
"They may need a feeding tube.”. This suggestion can be alarming and may not be appropriate without understanding the full context of the client's eating habits. Feeding tubes are considered only when other interventions have failed.
Choice C rationale
"Have you tried offering different foods?" While this might be helpful, it does not address the underlying issues. Gathering more information about the current mealtime situation is crucial before suggesting specific interventions.
Choice D rationale
"Let's discuss ways to encourage their appetite.”. This response is proactive but still doesn't gather enough information about the current situation. Understanding the specifics of mealtime behavior is necessary to provide tailored advice.
Correct Answer is C
Explanation
Choice A rationale
Applying suction while inserting the catheter is incorrect and can cause tissue damage and hypoxia. Suction should only be applied while withdrawing the catheter to prevent injury to the tracheal mucosa.
Choice B rationale
Applying intermittent suction for up to 30 seconds is excessive and can cause hypoxia and trauma to the trachea. The correct duration for intermittent suctioning is 10-15 seconds per pass to minimize these risks.
Choice C rationale
Preoxygenating the client prior to suctioning helps prevent hypoxia by ensuring the client has adequate oxygen reserves during the procedure. This is a standard practice to enhance patient safety during suctioning.
Choice D rationale
Instructing the client to swallow during catheter insertion is inappropriate and can lead to gagging or aspiration. The client should be relaxed and still during insertion to prevent complications.
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