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Difficulty: MediumAccident, Error, and Injury Prevention

The practical nurse (PN) is conducting a routine safety audit on a medical-surgical unit. Which observation requires the PN to immediately intervene to prevent a potential client injury or adverse event?

  1. A client who is newly agitated is placed in physical wrist restraints before any less restrictive interventions are attempted.Answer
  2. B
    An unlicensed assistive personnel (UAP) removes their contaminated gloves before untying and removing their isolation gown.
  3. C
    A newly licensed PN accepts a delegated assignment to administer routine oral medications to a clinically stable client.
  4. D
    A staff member notifies the healthcare provider about an older adult client who developed sudden, unexpected disorientation during the shift.

Answer

A client who is newly agitated is placed in physical wrist restraints before any less restrictive interventions are attempted.
Applying physical restraints should always be a measure of last resort. The standard of care requires that less restrictive alternative measures (such as frequent reorientation, decreasing environmental stimulation, offering a diversion, or involving a sitter) must be attempted and documented before restraints are utilized to prevent injury, skin breakdown, and psychological distress. Observing this premature application of restraints requires immediate intervention by the PN.

Step-by-Step Solution

1
Analyze the scenario to determine the objective.
The PN must identify which of the four observations represents an unsafe clinical practice that poses an immediate risk of injury or error.
Identifying safety hazards and stepping in to correct them is a primary nursing responsibility to prevent adverse events.
2
Evaluate the observation regarding the application of physical restraints.
Applying restraints without first trying alternative methods is a severe safety and ethical violation.
Physical restraints can cause injury, agitation, and loss of dignity. They are strictly a measure of last resort after alternatives (e.g., reorientation, distraction, family involvement) have failed.
3
Evaluate the remaining observations for safety compliance.
Removing gloves before gowns, accepting a stable medication assignment, and reporting acute confusion in the elderly are all correct, evidence-based practices.
These actions adhere to standard infection control protocols, the PN scope of practice, and appropriate geriatric nursing principles.

Key Concept

Accident, Error, and Injury Prevention: Restraint Alternatives and Safety Practices
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Topics

Accident, Error, and Injury Prevention

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