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Difficulty: Very hardAccident, Error, and Injury Prevention

A practical nurse (PN) is in the hallway preparing medications. Through the glass door, the PN observes an older adult client who is on strict contact precautions for a multidrug-resistant infection. The previously alert and oriented client is now acutely agitated, attempting to climb over the raised bedrails, and forcefully pulling at their peripheral intravenous (IV) line. What is the priority action for the PN to prevent client injury while maintaining unit safety?

  1. Rapidly don an isolation gown and gloves, enter the room to physically redirect the client's hands, and use the call light to request registered nurse (RN) assistance.Answer
  2. B
    Enter the room immediately to prevent a fall and IV dislodgment, secure the client safely, and perform thorough hand hygiene after leaving.
  3. C
    Delegate an unlicensed assistive personnel (UAP) to enter the room and assess the client's neurological status to determine the cause of the sudden confusion.
  4. D
    Attribute the sudden agitation to expected age-related cognitive decline, and instruct the client over the room's intercom system to remain in bed.

Answer

The correct action is to rapidly don an isolation gown and gloves, enter the room to physically redirect the client, and request RN assistance.
In any clinical emergency, the nurse must adhere to infection control standards to prevent becoming a vector for disease transmission. Donning the required personal protective equipment (PPE) for contact precautions is mandatory before entering the room, even when a client is at risk for a fall or injury. Once protected, the PN should use the least restrictive measure—physical redirection—to prevent harm and immediately call for RN assistance to assess the sudden change in the client's mental status.

Step-by-Step Solution

1
Identify the immediate safety threats and environmental constraints.
The client is at high risk for a fall and IV dislodgment, but is also on strict contact precautions.
Recognizing all variables is essential for comprehensive safety prioritization.
2
Determine the priority sequence between personal safety/infection control and client intervention.
The nurse must don appropriate personal protective equipment (PPE) before entering the room.
Facility infection control protocols dictate that a nurse must never become a vector for disease transmission, even during urgent client events.
3
Select the safest, least restrictive immediate intervention for the client.
Enter the room and physically redirect the client's hands away from the IV and bedrails.
Physical redirection prevents immediate harm without resorting to unauthorized physical or chemical restraints.
4
Escalate the situation to the appropriate level of care.
Use the call light to request the registered nurse (RN).
An acute, sudden change in mental status (delirium) requires comprehensive nursing assessment and clinical judgment, which falls under the RN's scope of practice.

Key Concept

Infection Control and Prioritization in Emergency Situations
Estimated Time:2m 0s
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Topics

Accident, Error, and Injury Prevention

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