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

Suggesting that the family member contact a grief counselor may be helpful, but it does not address their immediate need to help. Involving the family member in care can provide emotional support and a sense of purpose.

Choice B rationale

Describing a personal experience with the death of a family member may offer empathy but can shift the focus away from the client's needs. It is essential to keep the conversation centered on the family member's desire to help.

Choice C rationale

Including the family member in providing care for the client is an appropriate action. It allows them to participate actively, provides emotional support, and can be comforting for both the client and the family member.

Choice D rationale

Asking if the family member has had prior experience with the death of a family member may be relevant but does not directly address their desire to help. It is more effective to involve them in the care process immediately. .

A. Flex hips and knees when assisting the client to a standing position. B. Pivot on the foot farthest from the bed when assisting the client into the chair. C. Stand on the client's stronger side when moving the client into the chair. D. Raise the bed to waist level before moving the client.

Correct Answer is A

Explanation

Choice A rationale

Flexing hips and knees when assisting the client to a standing position provides a stable and balanced stance, reducing the risk of injury to both the nurse and the client. It ensures proper body mechanics and safety during the transfer.

Choice B rationale

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect as it can cause instability and increase the risk of falls. It is important to pivot on the foot closest to the bed to maintain a stable center of gravity.

Choice C rationale

Standing on the client's stronger side when moving the client into the chair is not ideal because the nurse should provide support on the weaker side, ensuring the client is balanced and stable during the transfer.

Choice D rationale

Raising the bed to waist level before moving the client is a correct action to ensure proper body mechanics and reduce strain on the nurse's back. However, it is not as critical as ensuring proper support and stability during the transfer process. .

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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?

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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?