Examkin

Question

Difficulty: MediumAccident, Error, and Injury Prevention

A hospital's rapid response team is deactivated after stabilizing a client, and the primary nurse returns to the general care environment where several safety-related events are occurring simultaneously. Which event represents the greatest immediate threat to client safety and dictates the nurse's immediate priority?

  1. An unlicensed assistive personnel (UAP) is actively feeding a client who sustained a severe ischemic stroke and is now exhibiting a wet, gurgling voice.Answer
  2. B
    A client with delirium is being placed in bilateral soft wrist restraints by another staff member who bypassed required de-escalation protocols and alternative measures.
  3. C
    A family member enters the negative-pressure room of a client with disseminated herpes zoster while wearing a standard surgical mask instead of a fitted N95 respirator.
  4. D
    The bed exit alarm continuously sounds for a confused client who received a dose of intravenous lorazepam thirty minutes ago.

Answer

The nurse must first intervene with the unlicensed assistive personnel (UAP) who is feeding the stroke client with a wet, gurgling voice.
The situation involving the UAP feeding the stroke client represents an active, immediate threat to the client's airway. A brainstem infarction carries a high risk of dysphagia, and a wet, gurgling voice is a cardinal sign of aspiration. According to the ABCs (Airway, Breathing, Circulation) of prioritization, an active airway threat takes absolute precedence over infection control breaches, restraint protocols, or fall risks. Furthermore, initial feeding and swallowing assessments must be performed by a registered nurse or speech-language pathologist, making this a dangerous, improper delegation.

Step-by-Step Solution

1
Identify the core safety hazard or protocol breach occurring in each of the four simultaneous scenarios.
Scenario 1: Airway threat and improper delegation. Scenario 2: Violation of restraint protocols. Scenario 3: Breach of airborne infection isolation precautions. Scenario 4: Immediate fall risk.
Understanding the nature and physiological impact of each error is the first step in clinical prioritization.
2
Apply the ABCs (Airway, Breathing, Circulation) framework and Maslow's Hierarchy of Needs to rank the hazards.
The stroke client being fed has a wet, gurgling voice, which is a cardinal sign of active aspiration (Airway). The bed exit alarm is a safety/circulation risk (Falls). The isolation breach is an infection risk. The restraint issue is a legal/protocol violation.
Prioritization frameworks dictate that immediate physiological threats to life, specifically airway compromises, must be addressed before safety, infection control, or procedural issues.
3
Select the intervention that addresses the highest-ranked hazard.
The nurse must immediately stop the UAP from feeding the stroke client to clear the airway and prevent fatal aspiration or respiratory failure.
Stopping an active aspiration event takes precedence over responding to a potential fall, correcting PPE usage, or enforcing restraint documentation.

Key Concept

Prioritization of Safety Hazards (ABCs and Delegation)
Rate this question

Topics

Accident, Error, and Injury Prevention

More questions from this topic