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Difficulty: HardAccident, Error, and Injury Prevention

A charge nurse is conducting safety rounds on a medical-surgical unit. Which of the following observed situations require the nurse to intervene immediately to prevent an accident, error, or injury? (Select all that apply.)

  1. A client with a new right-sided hemiparesis is holding a straight cane in their right hand while ambulating.Answer
  2. A client receiving continuous oxygen therapy via nasal cannula applies a petroleum-based lip balm to cracked lips.Answer
  3. An unlicensed assistive personnel (UAP) is silencing a high-pressure alarm on a client's enteral feeding pump.Answer
  4. D
    A nurse wears a gown, gloves, and a face shield when emptying a surgical wound drain for a client colonized with methicillin-resistant Staphylococcus aureus (MRSA).
  5. E
    A nurse secures a client's soft wrist restraint to the movable portion of the bed frame using a quick-release tie.
  6. A nurse prepares to transport a client with active pulmonary tuberculosis to the radiology department without placing a surgical mask on the client.Answer

Answer

The situations requiring intervention include the client using the cane on the weak side, the use of flammable petroleum jelly with oxygen, the UAP troubleshooting a pump alarm, and transporting a TB client without a mask.
The correct answers represent practices that violate safety standards and require immediate intervention. Canes must be held on the unaffected side to widen the base of support. Petroleum products are combustible and hazardous near oxygen. UAPs are not qualified to assess or troubleshoot medical pump alarms. Finally, clients with airborne infections like tuberculosis must wear a standard surgical mask during transport to prevent environmental contamination.

Step-by-Step Solution

1
Analyze the stem to determine the priority.
The nurse must identify which observed situations are unsafe and require intervention to prevent harm.
This is an evaluation of multiple distinct safety concepts in a clinical setting.
2
Evaluate the mobility and environmental hazards.
The cane in the right hand for right-sided hemiparesis is unsafe (should be left). The petroleum lip balm is a fire hazard with oxygen.
Both represent immediate risks for falls and fire, respectively, requiring intervention.
3
Evaluate the delegation and infection control scenarios.
The UAP managing a pump alarm is a scope of practice violation. Transporting a TB patient without a mask is an infection control violation.
Both actions risk severe errors or disease transmission and require intervention.
4
Evaluate the remaining clinical actions.
Wearing PPE while emptying a drain for an MRSA client and securing restraints to the movable bed frame with a quick-release knot are both safe, standard practices.
These actions follow established safety guidelines and do not require intervention.

Key Concept

Accident, Error, and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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