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Difficulty: MediumAccident, Error, and Injury Prevention

During a daytime shift, a practical nurse (PN) is caring for a 78-year-old client who was admitted two days ago for pneumonia. The client suddenly becomes disoriented, continuously attempts to remove their intravenous (IV) catheter, and tries to climb over the bed rails. Which of the following actions should the PN take to promote a safe environment? Select all that apply.

  1. Keep the bed in the lowest position with the wheels locked.Answer
  2. B
    Apply bilateral soft wrist restraints to prevent the client from dislodging the IV catheter.
  3. C
    Administer a prescribed intravenous push (IVP) sedative as delegated by the registered nurse (RN).
  4. Activate the bed exit alarm system to alert staff of movement.Answer
  5. E
    Reassure the family that sudden disorientation is a normal, expected part of the aging process.
  6. Request to relocate the client to a room closer to the nursing station for closer observation.Answer

Answer

The nurse should keep the bed in the lowest position, activate the bed exit alarm, and relocate the client closer to the nursing station.
To ensure client safety in the least restrictive manner, the nurse must implement measures that reduce the risk of falls and allow for rapid intervention. Keeping the bed in its lowest position minimizes fall impact, activating a bed exit alarm provides immediate notification of unsafe movement, and moving the client closer to the nursing station allows for frequent visual monitoring.

Step-by-Step Solution

1
Analyze the client's presentation and current risks.
The client is experiencing acute confusion, attempting to pull medical devices (IV catheter), and showing high fall risk behaviors (climbing over bed rails).
Identifying the specific safety threats is necessary to select appropriate interventions.
2
Evaluate interventions based on the principle of least restrictive environment and scope of practice.
Non-restrictive measures (bed position, alarms, relocation) must be prioritized over physical restraints. Delegation tasks must also remain within the PN scope of practice.
Standard nursing guidelines mandate exhausting less restrictive alternatives before utilizing restraints, and PNs must legally operate within their defined scope to prevent errors.
3
Select the correct actions from the provided options.
Keeping the bed low, using a bed exit alarm, and moving the client closer to the nursing station are safe, in-scope, and non-restrictive actions.
These actions directly mitigate the risk of injury while adhering to ethical and legal nursing standards.

Key Concept

Prioritizing least restrictive safety measures and adhering to the practical nurse (PN) scope of practice when managing acute delirium and fall risks.
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Topics

Accident, Error, and Injury Prevention

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