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 ["B","C","D"]

Explanation

Choice A rationale

Increased peripheral circulation is not a typical part of the aging process. In fact, aging is often associated with decreased circulation due to vascular changes and reduced cardiac output.

Choice B rationale

Constipation is more common in older adults due to factors like reduced intestinal motility, decreased fluid intake, and medication side effects, making it a relevant physiological change in aging.

Choice C rationale

Decreased muscle mass, or sarcopenia, is a common part of aging. It results from a combination of reduced physical activity, hormonal changes, and nutritional deficiencies.

Choice D rationale

A decreased cough reflex in older adults increases the risk of aspiration and respiratory infections. It results from changes in neurological function and reduced muscle strength.

A. Inject air into the ampule prior to drawing the medication into a syringe. B. Add 0.5 mL of diluent to the medication. C. Use a filter needle to aspirate the medication. D. Cleanse the tip of the ampule with an alcohol swab after opening.

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.

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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

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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?