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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
Correct Answer is D
Explanation
A. Delegate low-skilled tasks to assistive personnel.
Delegating low-skilled tasks to assistive personnel is not consistent with the total patient care delivery method. In this model, the nurse assumes responsibility for providing comprehensive care to a smaller number of patients rather than delegating tasks to others. The nurse remains directly involved in all aspects of patient care, including assessment, planning, implementation, and evaluation.
B. Receive cross-training in multiple departments
Receiving cross-training in multiple departments may be beneficial in some healthcare settings but is not a characteristic of the total patient care delivery method. This model focuses on nurses providing individualized care to a specific group of patients within their assigned unit. Cross-training in multiple departments would not align with this model, as it could lead to divided attention and potentially compromise the quality of care provided.
C. Perform a specific nursing task for a group of clients.
Performing a specific nursing task for a group of clients is not consistent with the total patient care delivery method. In this model, the nurse is responsible for providing comprehensive care to a smaller number of patients, rather than focusing on specific tasks for multiple patients. Each patient's care is individualized and encompasses all aspects of nursing care, not just specific tasks.
D. Provide complete care for a caseload of clients.
Providing complete care for a caseload of clients is characteristic of the total patient care delivery method. In this model, the nurse assumes responsibility for the holistic care of a smaller number of patients during each shift. This approach allows for continuity of care, fosters therapeutic nurse-patient relationships, and promotes better patient outcomes.
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