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

Answer: C

Rationale:

C) "It sounds like you have concerns about the procedure."
This response is therapeutic and encourages the client to express their concerns, allowing the nurse to understand the client's feelings without judgment. It opens up a supportive dialogue where the client can discuss their fears, anxieties, or misconceptions about the colostomy, which can then be addressed appropriately.

A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.

B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.

D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.

A. Use diluted bleach to clean soiled equipment. B. Provide a room with negative-pressure airflow. C. Wear an N95 respirator when caring for the client. D. Disinfect hands using an alcohol-based waterless antiseptic.

Correct Answer is A

Explanation

A) Use diluted bleach to clean soiled equipment: This is the correct answer. Clostridium difficile is a bacterium that can form spores, which are resistant to many common disinfectants. Diluted bleach (sodium hypochlorite) is effective in killing C. difficile spores, making it an essential part of infection control protocols for clients with C. difficile infection. It is recommended to use a dilution of 1:10 bleach to water for environmental cleaning.

B) Provide a room with negative-pressure airflow: While negative-pressure rooms may be used for clients with certain airborne infections to prevent the spread of pathogens, it is not typically necessary for clients with C. difficile infection. Standard precautions, including meticulous hand hygiene and appropriate environmental cleaning, are the primary measures for preventing transmission.

C) Wear an N95 respirator when caring for the client: N95 respirators are recommended for healthcare workers caring for clients with airborne infections such as tuberculosis or certain respiratory viruses. C. difficile is transmitted primarily through contact with contaminated surfaces or feces, so standard precautions, including gloves and gowns, are sufficient for preventing transmission.

D) Disinfect hands using an alcohol-based waterless antiseptic: While alcohol-based hand sanitizers are effective against many types of bacteria and viruses, they may not be sufficient for eliminating C. difficile spores. Handwashing with soap and water is preferred for removing C. difficile spores from hands.

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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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