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Difficulty: HardAccident, Error, and Injury Prevention

A 76-year-old client with chronic obstructive pulmonary disease (COPD) is receiving continuous oxygen therapy via nasal cannula. The client abruptly becomes highly combative, rips off the oxygen tubing, and begins thrusting their legs over the lowered side rails. To prevent immediate injury and manage the situation safely, which action is the priority for the practical nurse (PN)?

  1. Remain at the bedside to provide direct supervision, call for staff assistance, and prioritize the assessment of the client's respiratory status.Answer
  2. B
    Promptly apply soft bilateral wrist restraints to protect the client from self-injury and ensure the oxygen therapy remains intact.
  3. C
    Secure the client by raising all four side rails, attributing the sudden disorientation and combativeness to an expected manifestation of advanced age.
  4. D
    Focus immediately on physically pinning the client's limbs to the bed to prevent a fall, delaying the evaluation of the client's airway and breathing.

Answer

The priority action is to remain at the bedside for immediate direct supervision, request assistance, and promptly assess the client's respiratory status.
The correct action prioritizes both immediate client safety and physiological stability. By remaining at the bedside and calling for assistance, the PN implements a less restrictive safety measure (direct supervision) to prevent a fall. Concurrently, by prioritizing the assessment of the client's respiratory status, the PN addresses the most probable cause of the sudden agitation (acute hypoxia), adhering to the ABCs (Airway, Breathing, Circulation) of nursing care.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting sudden, acute combativeness and has removed their oxygen supply, presenting both an immediate fall risk and a severe respiratory threat.
Identifying the simultaneous safety and physiological risks is essential for accurate prioritization.
2
Correlate the behavioral change with potential physiological causes.
Sudden agitation and confusion in a client with a history of COPD is a primary indicator of acute hypoxia (delirium), not an expected age-related cognitive decline.
Understanding the root physiological cause prevents the inappropriate use of physical restraints for a medical problem.
3
Evaluate the proposed interventions against safety guidelines.
Physical restraints, including raising all four side rails or pinning the client's limbs, are interventions of last resort and can increase the risk of injury if the client struggles.
Nurses must always attempt less restrictive alternatives first to maintain a safe environment.
4
Select the optimal priority action.
Remaining at the bedside provides an immediate, non-restrictive safety measure, while calling for help allows the nurse to concurrently assess the ABCs (Airway, Breathing, Circulation).
This action simultaneously addresses immediate injury prevention and the critical physiological deficit.

Key Concept

Prioritizing less restrictive restraint alternatives while simultaneously addressing acute physiological needs (ABCs) to prevent client injury.
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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