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?

Tying the restraint to the bed frame

Applying the restraint over the client's gown

Placing the restraint across the client's chest

Using a quick-release knot to secure the restraint

Answer and Explanation

The Correct Answer is C

A) Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.

B) Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.

C) Placing the restraint across the client's chest: Placing the restraint across the client's chest is not recommended because it can restrict chest expansion and interfere with breathing, potentially leading to respiratory compromise. Restraints should be applied to minimize movement while allowing the client to breathe comfortably.

D) Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.

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Correct Answer is C

Explanation

A) "I will attempt to extinguish the fire before calling the fire department.": This statement indicates a misunderstanding of fire safety principles. It's crucial for individuals to prioritize their safety and evacuate the premises immediately in the event of a fire. Attempting to extinguish the fire before calling the fire department can waste valuable time and put the individual at risk.

B) "I should change the batteries in my smoke alarms every 2 years.": While changing smoke alarm batteries regularly is essential for ensuring they function properly, the recommended interval for battery replacement is typically every 6 months, not every 2 years. This statement reflects a misunderstanding of the recommended maintenance schedule for smoke alarms.

C) “I should spray the extinguisher from side to side on the fire.": This statement demonstrates an understanding of proper fire extinguisher use. When using a fire extinguisher, it's essential to aim the extinguisher nozzle at the base of the fire and sweep it from side to side until the fire is extinguished. This technique helps to smother the flames effectively and prevent re-ignition.

A. Assist in checking a unit of packed RBCS to administer to a client. B. Regulate the client's infusion pump after initiating a heparin drip infusion. C. Teach a client about hemodialysis. D. Create a plan of care for a client's discharge.

Correct Answer is ["A","B","C","D"]

Explanation

A) Assist in checking a unit of packed RBCS to administer to a client:

Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.

B) Regulate the client's infusion pump after initiating a heparin drip infusion:

Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.

C) Teach a client about hemodialysis:

Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.

D) Create a plan of care for a client's discharge:

Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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