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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A client admitted with measles (rubeola) is experiencing acute confusion and repeatedly attempts to climb out of bed. The client requires airborne precautions. Which action should the nurse take to ensure the client's safety while maintaining proper infection control?

  1. Assign a trained safety sitter to remain inside the client's room while wearing a fit-tested N95 respirator.Answer
  2. B
    Keep the door to the negative pressure room open to allow staff to continuously observe the client.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to assess the client's level of orientation every 15 minutes.
  4. D
    Obtain a prescription to apply bilateral soft wrist restraints to immediately prevent a potential fall.

Answer

Assign a trained safety sitter to remain inside the client's room while wearing a fit-tested N95 respirator.
The correct action prioritizes the client's physical safety by providing continuous observation (a sitter) while strictly adhering to airborne infection control protocols (requiring an N95 respirator). This utilizes a less restrictive alternative to restraints without compromising the safety of the healthcare environment.

Step-by-Step Solution

1
Analyze the client's clinical needs.
The client has two competing priorities: high risk for injury due to confusion and the need for strict airborne isolation for measles.
Identifying all risk factors ensures that interventions address physical safety without inadvertently breaking infection control protocols.
2
Evaluate potential safety interventions for fall prevention.
Restraints are recognized as a last resort. Less restrictive alternatives, such as 1:1 continuous observation (a sitter), must be utilized first.
Nursing standards and legal guidelines mandate the use of the least restrictive methods possible to preserve client autonomy and prevent restraint-related trauma.
3
Determine the infection control requirements for the chosen safety intervention.
The safety sitter must be stationed inside the room with the door closed and must wear an N95 respirator.
Because measles is spread via airborne droplet nuclei, the negative pressure environment must be maintained (closed door), and any personnel in the room must have appropriate respiratory protection.

Key Concept

Balancing injury prevention through least restrictive alternatives with strict adherence to transmission-based precautions.
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Topics

Accident, Error, and Injury Prevention

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