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 D

Explanation

Choice A rationale

Isopropyl alcohol is effective for general disinfection but is not the best choice for cleaning blood spills because it does not completely eliminate all pathogens, especially certain viruses like hepatitis B.

Choice B rationale

Hydrogen peroxide is not typically used for blood spills as it is less effective against certain pathogens compared to other disinfectants and can potentially damage surfaces over time.

Choice C rationale

Chlorhexidine gluconate is used for skin antisepsis rather than environmental disinfection. It is not the best option for cleaning blood spills due to its limited efficacy against all bloodborne pathogens.

Choice D rationale

Chlorine bleach is the recommended solution for cleaning blood spills as it is highly effective in killing a wide range of pathogens, including viruses like HIV and hepatitis B, ensuring a safe and sanitized area.

A. A client who has ulcerative colitis. B. A client who has cholecystitis. C. A client who uses laxatives. D. A client who has stomatitis.

Correct Answer is A

Explanation

Choice A rationale

Ulcerative colitis often results in inflammation and ulcers in the colon lining, which can lead to bleeding and a positive fecal occult blood test. This is a common complication of the condition.

Choice B rationale

Cholecystitis, an inflammation of the gallbladder, does not typically cause gastrointestinal bleeding or a positive fecal occult blood test. It is more associated with abdominal pain and digestive issues.

Choice C rationale

The use of laxatives generally does not cause internal bleeding that would result in a positive fecal occult blood test. Laxatives are more likely to cause changes in bowel habits and diarrhea.

Choice D rationale

Stomatitis, inflammation of the mouth, is unlikely to cause a positive fecal occult blood test. It primarily affects the oral cavity and is not associated with gastrointestinal bleeding. .

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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?