While completing client rounds in a long-term care facility, a practical nurse (PN) observes an assistive personnel (AP) attempting to increase the flow rate on a client's continuous enteral feeding pump. Arrange the following actions the PN should take in the correct chronological order of priority.
- 1Direct the assistive personnel to immediately cease interacting with the enteral feeding pump.
- 2Perform focused data collection on the client to identify any signs of respiratory distress or discomfort.
- 3Verify the healthcare provider's orders and restore the pump to the prescribed flow rate.
- 4Discuss the legal boundaries of delegation with the assistive personnel in a private setting.
- 5Report the unauthorized scope of practice breach to the supervising registered nurse.
Answer
The correct sequence prioritizes immediate client safety, physiological assessment, equipment correction, staff education, and administrative escalation.
In any clinical situation where an unauthorized or unsafe action is observed, the nursing process dictates a specific priority hierarchy. The nurse must first intervene directly to stop the action and prevent harm. Immediately following, the nurse must perform data collection on the client to identify if any injury has already occurred. Once the client is deemed safe, the therapeutic environment is restored (verifying and resetting the pump). Only after client safety is fully secured does the nurse address the interpersonal and administrative tasks of educating the personnel and reporting the breach to the supervising registered nurse.
Step-by-Step Solution
Key Concept
Prioritization of Care and Delegation Boundaries