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Difficulty: HardAccident, Error, and Injury Prevention

A registered nurse is developing a plan of care for an 80-year-old client admitted with a severe urinary tract infection (UTI). The client has developed acute delirium, is highly agitated, and repeatedly attempts to climb over the bed rails unassisted. Which of the following interventions should the nurse implement to prevent injury and mitigate clinical errors? (Select all that apply.)

  1. Activating a weight-sensitive bed exit alarm to promptly alert staff if the client attempts to leave the bedAnswer
  2. Relocating the client to a room near the nurses' station to facilitate frequent visual monitoringAnswer
  3. C
    Delegating the completion of the initial comprehensive fall risk assessment to the unlicensed assistive personnel (UAP)
  4. D
    Obtaining a prescription to apply a vest restraint immediately to prevent the client from climbing over the rails
  5. E
    Documenting the client's sudden agitation and acute confusion as an expected age-related cognitive change
  6. Maintaining the client's bed in the lowest locked position and ensuring the immediate environment is free of clutterAnswer

Answer

The correct safety interventions include activating a bed exit alarm, relocating the client near the nurses' station, and keeping the bed in the lowest locked position while clearing environmental clutter.
Implementing a bed exit alarm, relocating the client near the nurses' station for closer observation, and maintaining a low, locked bed with a clutter-free environment are all evidence-based, primary interventions to prevent falls and injury. These actions prioritize client safety using the least restrictive methods available, adhering to standard nursing protocols for an agitated client at high risk for falls.

Step-by-Step Solution

1
Analyze the client's clinical presentation and identify primary safety risks.
The client is an older adult experiencing acute delirium secondary to an infection, exhibiting high agitation, and attempting unsafe bed exits, which creates a severe fall and injury risk.
Identifying the specific behavioral and environmental safety hazards is the foundational step in formulating a targeted injury prevention plan.
2
Evaluate each potential intervention for safety, appropriateness, and compliance with nursing standards.
Bed alarms, frequent direct monitoring, and a safe physical environment are evidence-based, less-restrictive safety measures. Conversely, immediate restraint use, delegating initial clinical assessments, and misattributing acute pathology to normal aging represent unsafe practices and critical clinical errors.
Nursing protocols require prioritizing the least restrictive safety measures and maintaining strict adherence to delegation limits and assessment standards to prevent errors and patient harm.

Key Concept

Injury Prevention and Restraint Alternatives
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Topics

Accident, Error, and Injury Prevention

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