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Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse is caring for a client with active pulmonary tuberculosis who is experiencing acute delirium. The client is confused and repeatedly attempts to leave the negative-pressure isolation room to wander in the hallway. Which nursing action is most appropriate to prevent injury and maintain unit safety?

  1. A
    Apply a physical bed alarm and leave the isolation room door partially open to allow direct visual monitoring.
  2. Assign a dedicated staff member to remain continuously inside the client's room while wearing an N95 respirator.Answer
  3. C
    Apply bilateral soft wrist restraints to secure the client in bed and prevent a breach of isolation.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to evaluate the client's level of orientation and agitation every 15 minutes.

Answer

Assign a dedicated staff member to remain continuously inside the client's room while wearing an N95 respirator.
The most appropriate intervention is to provide a dedicated staff sitter inside the room. This maintains strict airborne isolation by allowing the door to remain closed while utilizing a less restrictive alternative to physical restraints to ensure the safety of a confused client. The staff member must wear appropriate personal protective equipment, including a fit-tested N95 respirator, to prevent disease transmission.

Step-by-Step Solution

1
Identify the primary safety risks presented by the client.
The client poses a disease transmission risk due to tuberculosis and a personal injury risk due to delirium and wandering.
Recognizing dual risks dictates that the chosen intervention must address both concerns safely.
2
Evaluate interventions for infection control compliance.
The negative-pressure room door must remain closed at all times.
Leaving the door open compromises the negative pressure environment and exposes others in the facility to airborne pathogens.
3
Apply the principle of least restrictive restraints.
A 1:1 sitter is chosen over physical restraints.
Safety guidelines mandate attempting less restrictive alternatives (like a sitter or reorientation) before applying physical restraints to a confused client.
4
Determine appropriate delegation of tasks.
The task of evaluating neurological status is retained by the registered nurse.
Clinical assessment and judgment regarding a client's orientation and agitation level are outside the scope of practice for unlicensed assistive personnel.

Key Concept

Maintaining a safe environment through strict adherence to airborne precautions, utilizing least restrictive alternatives for confused clients, and applying safe delegation principles.
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Topics

Accident, Error, and Injury Prevention

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