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

Orthostatic hypotension is characterized by a sudden drop in blood pressure when standing up, often due to dehydration, medication side effects, or autonomic dysfunction. While concerning, it is not a direct risk factor for cardiovascular disease.

Choice B rationale

A BMI of 24 is within the normal range (18.5–24.9) and is not considered a risk factor for cardiovascular disease. Maintaining a healthy BMI is part of cardiovascular disease prevention.

Choice C rationale

Type 1 diabetes mellitus significantly increases the risk of cardiovascular disease due to its impact on blood vessels and the heart. It is a well-documented risk factor requiring careful management.

Choice D rationale

A family history of osteoporosis is relevant for bone health but does not directly increase the risk of cardiovascular disease. Cardiovascular risk factors are more closely related to metabolic and lifestyle factors.

A. Apply clean gloves. B. Disconnect the tube from the suction device. C. Instill 50 mL of air into the tube. D. Ask the client to take a deep breath. E. Pinch and withdraw the tube.

Correct Answer is A,B,C,D,E

Explanation

A. Apply clean gloves.

B. Disconnect the tube from the suction device.

C. Instill 50 mL of air into the tube.

D. Ask the client to take a deep breath.

E. Pinch and withdraw the tube.

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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?