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Difficulty: Very hardHigh Risk Behaviors

A practical nurse (PN) is caring for a client with a history of intravenous substance use disorder who is receiving intravenous (IV) antibiotics. Upon entering the client's room, the PN observes the client actively attempting to inject an unknown clear liquid from a syringe directly into the peripheral IV line port. Arrange the following PN actions in the correct order of priority.

  1. 1Verbally direct the client to stop the injection and immediately clamp the intravenous tubing.
  2. 2Don gloves and safely secure the syringe out of the client's reach.
  3. 3Perform a focused assessment of the client's airway, breathing, circulation, and neurological status.
  4. 4Report the incident and assessment findings to the charge nurse and the healthcare provider.
  5. 5Document the event objectively in the medical record and complete a facility incident report.

Answer

The correct priority sequence is: 1. Clamp the IV tubing, 2. Secure the syringe, 3. Assess the client's physiological status, 4. Notify the RN and healthcare provider, 5. Document the event.
In acute situations involving high-risk behaviors and imminent danger, the nurse must prioritize interventions using Maslow's hierarchy of needs and fundamental safety principles. The immediate priority is to stop the physiological threat (clamping the IV). Next, the nurse secures the environment to prevent further harm. Once the scene is safe, the nurse collects data by assessing the client's current physiological status. This crucial assessment data is then communicated to the RN and healthcare provider to guide collaborative management. Finally, the nurse completes the legal and administrative requirement of documentation.

Step-by-Step Solution

1
Instruct the client to stop and clamp the IV tubing.
The flow of the unknown substance into the client's bloodstream is halted.
Stopping active, immediate harm is the highest priority in any emergency scenario, superseding the standard 'assess first' rule.
2
Secure the syringe safely away from the client.
The immediate environmental hazard is neutralized.
Securing the sharp object prevents the agitated client from attempting another injection and protects the nurse from occupational injury.
3
Assess airway, breathing, circulation, and neurological status.
The client's physiological stability is determined.
Data collection is necessary to ascertain if the client is experiencing an overdose or adverse reaction requiring immediate resuscitation.
4
Notify the charge nurse and healthcare provider.
The interdisciplinary care team is alerted.
The RN and provider require the assessment data to prescribe further interventions, such as administering antidotes or ordering toxicology screens.
5
Document the event and complete an incident report.
Legal and administrative records are updated.
Thorough documentation maintains accurate medical records and satisfies facility risk management protocols, but it is never a priority over direct client care.

Key Concept

Prioritization of Care: Acute High-Risk Behaviors
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Topics

High Risk Behaviors

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