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Difficulty: HardAccident, Error, and Injury Prevention

A registered nurse is caring for an older adult client with hepatic encephalopathy who is highly agitated, confused, and repeatedly attempting to climb over the bed rails. The client is receiving continuous intravenous (IV) fluids and has an active Clostridioides difficile infection requiring contact precautions. Which action by the nurse is the MOST appropriate priority intervention to prevent client injury?

  1. Activate the bed exit alarm, place the bed in the lowest position, and arrange for a dedicated staff member to provide one-to-one continuous observation.Answer
  2. B
    Place the client in a room near the nurses' station with the door open for visual monitoring, and use an alcohol-based hand sanitizer upon exiting the room.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to perform neurological assessments every 30 minutes and immediately report any worsening agitation.
  4. D
    Apply bilateral soft wrist restraints to protect the intravenous access and prevent an imminent fall, then immediately notify the healthcare provider.

Answer

Activate the bed exit alarm, place the bed in the lowest position, and arrange for a dedicated staff member to provide one-to-one continuous observation.
The most appropriate priority intervention is to utilize the least restrictive safety measures to protect the client. Activating the bed alarm, lowering the bed, and utilizing a trained sitter directly addresses the imminent risk of falling and device dislodgment without resorting to physical restraints. This approach adheres to the standard of care for injury prevention in agitated clients.

Step-by-Step Solution

1
Analyze the client's clinical presentation and associated risks.
The client is confused, agitated, and trying to climb out of bed, indicating an imminent high risk for falls and self-injury.
Identifying the primary safety risk dictates the urgency and type of intervention required.
2
Evaluate the restraint requirements and alternatives.
Restraints must be a last resort; less restrictive measures such as a bed alarm, low bed position, and a one-to-one sitter must be implemented first.
Standard safety and ethical guidelines mandate prioritizing the least restrictive environment to prevent injury.
3
Consider the client's infection control status.
The client has C. difficile, which requires contact precautions and hand washing with soap and water (not alcohol-based sanitizers).
Safety interventions must not violate strict infection control protocols.
4
Assess the scope of practice for delegation.
Neurological assessments cannot be delegated to unlicensed assistive personnel (UAP); they must be performed by the registered nurse.
Delegating nursing assessments violates the nursing scope of practice and jeopardizes client safety.

Key Concept

Safety Prioritization and Restraint Alternatives
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Topics

Accident, Error, and Injury Prevention

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