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.

Answer and Explanation

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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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Choice A rationale:

While hoarseness can be a symptom of aspiration pneumonia, it is not a direct cause. Hoarseness alone does not necessarily lead to aspiration pneumonia.

Choice B rationale:

Coughing when eating is a direct risk factor for aspiration pneumonia. Coughing indicates that food or liquid may be entering the airway, which can lead to aspiration pneumonia.

Choice C rationale:

Dysphagia (difficulty swallowing) can be a risk factor for aspiration pneumonia, but in this case, the client's symptoms (coughing when eating and hoarseness) are more directly associated with aspiration pneumonia.

Choice D rationale:

While coughing when eating can be a symptom of dysphagia, the primary concern here is the risk of aspiration pneumonia due to the same symptom.

A. Use a catheter securing device to hold the catheter in place. B. Obtain urine from the drainage bag if a urinary specimen is required. C. Change the catheter bag every 3 days and as needed. D. Position the drainage bag higher than the client's bladder.

Correct Answer is A

Explanation

Choice A rationale

Securing the catheter helps prevent it from moving, which reduces the risk of urethral trauma and infection. Proper fixation is essential for patient safety and comfort.

Choice B rationale

Urine should not be obtained from the drainage bag for specimen collection as it may be contaminated. Fresh urine samples directly from the catheter port are more accurate.

Choice C rationale

Catheter bags should be changed based on clinical need, which can be more frequent than every 3 days. This ensures hygiene and reduces infection risks.

Choice D rationale

The drainage bag should be kept below the bladder level to prevent backflow of urine, which can lead to infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a male client in the unit. Exhibits Complete the following sentence by using the list of options. The client is at risk for developing dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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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?