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 C

Explanation

Choice A rationale

Injecting air into the ampule prior to drawing the medication into a syringe can cause the medication to spill and is not a safe practice.

Choice B rationale

Adding 0.5 mL of diluent to the medication is not a standard procedure for medication administration from an ampule and can lead to incorrect dosing.

Choice C rationale

Using a filter needle to aspirate the medication is important to prevent glass particles from the broken ampule from entering the syringe and being administered to the patient.

Choice D rationale

Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary, as the medication is already inside the sealed ampule, and it can increase the risk of contamination.

A. "We can discuss this when you're not feeling overwhelmed.”. B. "Have you tried taking your partner with you when you go out?" C. "Tell me more about your expectations.”. D. "I understand how you feel. I've had a relative go through the same thing.”

Correct Answer is C

Explanation

Choice A rationale

Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.

Choice B rationale

Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.

Choice C rationale

Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.

Choice D rationale

While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.

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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 preparing to administer a medication from an ampule.Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

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Correct Answer is C

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?