Question 1

The assistive personnel (AP) informs the nurse that the client has pulled the IV catheter out again and is not oriented to time or place. Which task could the nurse safely assign to the AP at this time?

A) Applying wrist restraints
B) Calling the health care provider to obtain an order for restraints
C) Getting mitt restraints from the supply room and meeting the nurse in the client's room
D) Applying some form of restraint to limit the client's ability to pull the IV line out again

Accepted Answer

1. It is the nurse's responsibility to assess the client before making a decision to apply a restraint, so asking the AP to apply a restraint prior to the nurse's assessment would not be safe. The nurse should determine what type of restraint to use and should call the health care provider for an order. The AP could obtain restraints anticipated to be needed by the nurse and meet the nurse in the room to help with applying them after the nurse has completed the assessment.
2. It is the nurse's responsibility to assess the client before making a decision to apply a restraint, so asking the AP to apply a restraint prior to the nurse's assessment would not be safe. The nurse should determine what type of restraint to use and should call the health care provider for an order. The AP could obtain restraints anticipated to be needed by the nurse and meet the nurse in the room to help with applying them after the nurse has completed the assessment.
3. It is the nurse's responsibility to assess the client before making a decision to apply a restraint, so asking the AP to apply a restraint prior to the nurse's assessment would not be safe. The nurse should determine what type of restraint to use and should call the health care provider for an order. The AP could obtain restraints anticipated to be needed by the nurse and meet the nurse in the room to help with applying them after the nurse has completed the assessment.
4. It is the nurse's responsibility to assess the client before making a decision to apply a restraint, so asking the AP to apply a restraint prior to the nurse's assessment would not be safe. The nurse should determine what type of restraint to use and should call the health care provider for an order. The AP could obtain restraints anticipated to be needed by the nurse and meet the nurse in the room to help with applying them after the nurse has completed the assessment.

Question 2

A client is at risk for falling when getting out of bed without assistance. Which should the nurse do before placing a bed exit safety monitoring device in place?&#10;A) Obtain a health care provider's order&#10;B) Document the use of the alarm system&#10;C) Test the alarm&#10;D) Apply the leg band or sensor pad

Accepted Answer

1. There is no need for a health care provider's order, as this is an independent nursing action.
2. Documentation would occur after application of the system.
3. Before applying the system, the nurse should test the alarm to ensure that it works and is set high enough to be heard. It is also wise to allow the client to hear the alarm so it does not frighten the client when it goes off.
4. After testing the alarm, the nurse would apply the leg band or sensor pad.

Question 3

The nurse is instructing the assistive personnel (AP) on fall prevention for the clients. Which statement made by the AP warrants further instruction?&#10;A) &#34;I will ensure that the call light is within reach of the client.&#34;&#10;B) &#34;I will make sure to have at least one side rail up at all times.&#34;&#10;C) &#34;I don't have to worry about the clients who are bedridden, as they are moved by the staff.&#34;&#10;D) &#34;I will make sure that the bed is in the lowest position prior to leaving the room.&#34;

Accepted Answer

1. Ensuring that the call light is within reach of the client indicates appropriate understanding by the AP on fall prevention strategies for the client.
2. Leaving one side rail up at all times indicates an appropriate understanding by the AP on fall prevention strategies for the client.
3. The statement indicating not having to worry about clients who are bedridden because they are moved by staff is not correct as clients who are bedridden are more prone to falls due to the loss of independence.
4. Ensuring that the bed is in the lowest position possible prior to leaving the room indicates an appropriate understanding by the AP on fall prevention strategies for the client.

Question 4

The nurse is assigning supportive care to the assistive personnel (AP) for several clients on a medical-surgical unit. Which statement made by the AP warrants the need for more information?&#10;A) &#34;I can untie the restraint when giving the client a bath.&#34;&#10;B) &#34;I will make sure to tie the restraint in a slip-knot.&#34;&#10;C) &#34;I will inform you of any changes to the skin.&#34;&#10;D) &#34;I will assist the client with hygiene.&#34;

Accepted Answer

1. The AP should only untie the restraint while giving a bath if the client is no longer in danger of pulling out lines or becoming combative with staff. This statement indicates the need for the nurse to ask more questions of the AP.
2. The AP should tie the restraint in a slip-knot.
3. The AP should inform the nurse of any changes to the skin.
4. The AP should assist the client with hygiene.

Question 5

When putting a client in restraints, the nurse will need to assess the client per policy. Which areas should the nurse include when completing this assessment? Select all that apply.&#10;A) The client's range of motion&#10;B) That the client's restraint is tied in a knot&#10;C) The client's vital signs&#10;D) The client's circulation&#10;E) The client's hydration

Accepted Answer

1. When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
2. When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
3. When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
4. When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.
5. When the nurse is providing care to a client who is in restraints, appropriate items to assess include range of motion, vital signs, circulation, and hydration. The restraint knot should also be assessed but the restraint should be a slip knot, not a regular knot.

Deck 12: Fall Prevention, Restraints, and Seizure Precautions