A charge nurse is observing a newly licensed practical nurse (PN) provide care for several clients on a medical-surgical unit. Which action by the PN represents a safety hazard and requires immediate intervention by the charge nurse?
- ARemoving soiled gloves, protective eyewear, and gown inside the room, and removing the respirator mask after exiting the room.
- BReporting a sudden onset of severe agitation and disorientation in an 82-year-old client immediately to the registered nurse (RN).
- Raising all four full-length side rails on the bed of a restless, confused client to prevent a fall.Answer
- DDeclining a provider's request to independently administer a scheduled dose of intravenous (IV) push hydromorphone to a client in pain.
Answer
The action that represents a safety hazard is raising all four full-length side rails on the bed of a restless, confused client.
Raising all four full-length side rails constitutes a physical restraint and requires a provider's prescription. For a restless and confused client, this action creates a severe safety hazard because the client is likely to attempt to climb over the rails, resulting in a fall from a greater height and significantly increasing the risk of traumatic injury. Least restrictive alternatives, such as a bed alarm or placing the mattress close to the floor, must be used instead.
Step-by-Step Solution
Key Concept
The use of all four side rails is considered a physical restraint and increases the risk of severe injury in confused clients who may attempt to climb over them.
Estimated Time:1m 15s