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

Placing the specimen in a clean specimen cup is not appropriate for a urine culture and sensitivity test. A sterile specimen cup is required to avoid contamination and ensure accurate results.

Choice B rationale

Removing 45 mL of urine from the catheter with a syringe is incorrect. Only 5-10 mL of urine is needed for a culture and sensitivity test, and excessive removal can lead to inaccurate test results or sample contamination.

Choice C rationale

Clamping the catheter tubing below the needleless port is the correct action. This allows urine to accumulate in the tubing, providing a fresh and uncontaminated sample for the culture and sensitivity test.

Choice D rationale

Clamping the catheter tubing for 60 minutes is too long and can cause urine stasis, increasing the risk of catheter-associated urinary tract infections. The tubing should be clamped only for a short duration to collect an adequate sample. .

A. Pad bony prominences before applying a restraint. B. Tie the ends of the restraint to the client's bed rail. C. Use a square knot to secure the client's restraint to the bed. D. Observe the client's skin integrity every 2 hr. E. Ensure that 2 fingers can be placed between the restraint and the client.

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale

Pad bony prominences before applying a restraint to prevent skin breakdown and pressure sores. Bony areas are prone to pressure ulcers when subjected to prolonged pressure from restraints.

Choice B rationale

Restraint ends should never be tied to the client's bed rail because it can lead to injury if the bed rail is moved or adjusted. Proper technique involves securing restraints to a part of the bed frame that does not move.

Choice C rationale

A square knot should not be used to secure the client's restraint as it can be difficult to untie in an emergency. Instead, quick-release knots or buckle straps are preferred for safety and rapid removal.

Choice D rationale

Observing the client's skin integrity every 2 hours is crucial to identify any signs of skin irritation, pressure ulcers, or other complications early. Regular checks ensure prompt intervention if issues arise.

Choice E rationale

Ensuring that two fingers can be placed between the restraint and the client helps to maintain proper circulation and comfort, preventing too tight a restraint which can lead to circulatory and nerve damage.

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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?