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Difficulty: MediumAccident, Error, and Injury Prevention

A nurse preceptor is observing a newly hired registered nurse (RN) implement fall precautions for a client who experiences severe orthostatic hypotension. Which action by the newly hired RN requires immediate correction by the preceptor to prevent client injury?

  1. Instructing the unlicensed assistive personnel (UAP) to evaluate if the client's gait is steady enough for independent ambulationAnswer
  2. B
    Keeping the client's bed in the lowest possible position with three of the four side rails elevated
  3. C
    Instructing the client to sit on the edge of the bed for two to three minutes before attempting to stand
  4. D
    Securing the client's call light within immediate reach and instructing them to use it before getting out of bed

Answer

The action requiring immediate correction is instructing the unlicensed assistive personnel (UAP) to evaluate if the client's gait is steady enough for independent ambulation.
The registered nurse is legally responsible for all clinical assessments, including evaluating a client's tolerance to activity and stability during ambulation. Delegating this evaluation to an unlicensed assistive personnel (UAP) violates the principles of safe delegation and places a high-risk client in immediate danger of falling. The preceptor must intervene immediately to perform the assessment themselves.

Step-by-Step Solution

1
Identify the client's specific safety risks based on the clinical presentation.
The client has severe orthostatic hypotension, which significantly increases the risk of dizziness, syncope, and falls upon standing.
Understanding the mechanism of risk dictates which safety interventions are required.
2
Analyze each action performed by the newly hired RN to determine if it aligns with evidence-based safety protocols and scope of practice.
Three actions are correct safety measures (dangling legs, three side rails, call light access). One action involves delegating a clinical evaluation to a UAP.
The preceptor must identify unsafe practices or scope-of-practice violations to protect the client.
3
Select the action that places the client at risk and requires immediate correction.
The delegation of gait evaluation to the UAP is selected.
UAPs cannot perform assessments or evaluate clinical status; doing so jeopardizes client safety.

Key Concept

Safe Delegation and Fall Prevention Protocols
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Topics

Accident, Error, and Injury Prevention

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