A nurse is observing an assistive personnel (AP) apply a belt restraint on a client. Which of the following actions by the AP requires intervention by the nurse?

A) Ask ambulatory clients to help to move clients in wheelchairs:

While enlisting the help of ambulatory clients to assist those in wheelchairs may seem logical, it is not typically recommended as it could pose safety risks to both parties during an evacuation. Assistive personnel should be trained to prioritize their own safety and the safety of others during evacuation procedures, following established protocols for assisting clients with mobility impairments.

B) Place dry towels around the bases of doors:

Placing dry towels around the bases of doors is a recommended fire evacuation procedure to prevent smoke from entering the room. This action helps create a barrier to smoke inhalation and can buy time for evacuation or rescue efforts. It is important to use dry towels or clothing to avoid fueling the fire and to minimize the passage of smoke.

C) Carry bedridden clients to safety by lifting them onto your back:

Carrying bedridden clients on one's back during a fire evacuation is not a safe or feasible method, especially for assistive personnel who may not have the physical strength or training to perform such tasks. Evacuating bedridden clients should be done using appropriate evacuation equipment such as evacuation sleds or sheets, following facility protocols and guidelines.

D) Aim the extinguisher at the top of the fire:

While using a fire extinguisher is an important aspect of fire safety training, aiming the extinguisher at the top of the fire is not always the correct approach. The appropriate technique for using a fire extinguisher depends on the type of fire and the specific instructions provided with the extinguisher. It is essential for assistive personnel to receive proper training on fire extinguisher use and to follow established procedures during emergencies.

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.