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Difficulty: MediumAccident, Error, and Injury Prevention

A client receiving continuous intravenous (IV) fluids and prescribed opioid analgesics requires assistance when getting out of bed. Which safety measures should the practical nurse (PN) implement to prevent environmental hazards and client injury? Select all that apply.

  1. Place the bed in the lowest horizontal position with the wheels lockedAnswer
  2. B
    Raise all four bed side rails to deter the client from getting up independently
  3. Position the call bell, water pitcher, and eyeglasses within the client's immediate reachAnswer
  4. D
    Direct the unlicensed assistive personnel to evaluate the client's balance before bathroom trips
  5. Ensure the client is wearing nonskid footwear prior to any ambulationAnswer

Answer

The appropriate safety measures are placing the bed in the lowest locked position, positioning the call bell and personal items within immediate reach, and ensuring the use of nonskid footwear during ambulation.
Clients receiving opioid medications and continuous IV fluids are at a high risk for falls due to potential side effects like dizziness, sedation, and physical encumbrance. Evidence-based fall prevention includes modifying the environment to remove hazards. Keeping the bed in the lowest, locked position minimizes the distance of a potential fall. Placing the call bell and frequently used items within reach discourages unassisted attempts to get out of bed. Nonskid footwear provides essential traction to prevent slipping.

Step-by-Step Solution

1
Identify the client's risk factors based on the clinical scenario.
The client is receiving opioids (causing potential dizziness/sedation), has IV fluids (tethering), and requires assistance.
Understanding risk factors helps determine the necessary safety interventions.
2
Select interventions that modify the environment to reduce hazards.
Lowering and locking the bed, providing nonskid footwear, and keeping items in reach are selected.
These actions directly mitigate the risk of falling without restricting the client's freedom of movement.
3
Eliminate interventions that violate safety protocols or scope of practice.
Using four side rails and delegating an assessment task to unlicensed personnel are excluded.
Four side rails constitute a physical restraint, and assessing balance falls outside the scope of unlicensed staff.

Key Concept

Fall Prevention and Safety Precautions
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Topics

Accident, Error, and Injury Prevention

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