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 D
Explanation
Choice A rationale
Cleaning the hearing aid with isopropyl alcohol is inappropriate as it can damage the device. Hearing aids should be cleaned with a dry, soft cloth or a brush specifically designed for this purpose to maintain their functionality.
Choice B rationale
Turning the hearing aid off for 5 minutes does not address the underlying cause of the whistling sound, which is often due to feedback or improper fit. Proper troubleshooting and adjustment are necessary to resolve the issue.
Choice C rationale
Soaking the hearing aid in warm water is incorrect and can severely damage the electronic components of the device. Hearing aids must be kept dry and handled according to the manufacturer's instructions.
Choice D rationale
Decreasing the volume on the hearing aid can reduce or eliminate the whistling sound caused by feedback. Adjusting the volume or repositioning the device can help achieve optimal functionality without causing discomfort or distortion. .
Correct Answer is C
Explanation
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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