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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. Includes quotes from the client B. Remains logged in to the charting system throughout the shift C. Makes reference in the nurses notes of completing an incident report D. Documents that the provider wrote an inaccurate prescription

Correct Answer is A

Explanation

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A charge nurse is reviewing the computer documentation of a newly licensed nurse. Which of the following practices by the newly licensed nurse should the charge nurse identify as appropriate documentation practice?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information the nurse includes in the teaching?

A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

A nurse is working on a medical-surgical unit that uses the total patient care delivery method. For each shift, the nurse should plan to take which of the following actions?

A nurse is reinforcing teaching about ethical dilemmas with a newly licensed nurse. Which of the following should the nurse identify as the first step in the ethical reasoning process?

A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?