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Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse is providing care for a group of clients on a medical-surgical unit, including an older adult client experiencing acute delirium who is receiving continuous intravenous (IV) therapy. Which of the following actions by the nurse demonstrate appropriate accident, error, and injury prevention? (Select all that apply.)

  1. Positioning the delirious client's IV tubing and medical devices out of their direct visual field.Answer
  2. Activating a bed alarm and maintaining the delirious client's bed in the lowest locked position.Answer
  3. C
    Delegating the ongoing evaluation of the delirious client's neurological status to an unlicensed assistive personnel (UAP).
  4. D
    Applying soft wrist restraints to the delirious client immediately after noticing them reaching for the IV tubing.
  5. E
    Using an alcohol-based hand rub after cleaning a bedside commode used by a client with an active Clostridioides difficile infection.
  6. F
    Prioritizing a scheduled discharge teaching session for a stable client over assessing another client's sudden onset of severe respiratory distress.

Answer

The correct actions include positioning the IV tubing out of the client's visual field and activating the bed alarm with the bed in the lowest locked position.
Positioning medical devices out of the visual field reduces sensory stimulation and the temptation for a delirious client to pull at them, acting as an effective non-restrictive safety measure. Additionally, maintaining the bed in the lowest locked position with an active bed alarm mitigates fall risk and alerts staff immediately if the client attempts to ambulate unsafely.

Step-by-Step Solution

1
Identify the primary safety risks for the delirious client.
The client is at high risk for falls and pulling out necessary medical devices due to altered mental status.
Understanding specific risks guides the selection of appropriate, individualized safety interventions.
2
Evaluate each intervention against established safety protocols and the principle of least restrictive interventions.
Concealing tubing and using bed alarms are appropriate first-line measures. Restraints are a last resort and should not be applied immediately.
Safety must be maintained while preserving the client's dignity and avoiding unnecessary restriction that can worsen agitation.
3
Apply prioritization and delegation rules to the remaining scenarios on the unit.
Assessments cannot be delegated to UAP, ABCs always take priority over routine tasks, and hand hygiene for C. difficile requires soap and water.
Strict adherence to scope of practice, the nursing process, and infection control standards prevents systemic errors and patient harm.

Key Concept

Client safety requires prioritizing non-restrictive interventions, adhering to infection control and delegation standards, and always addressing unstable clients (ABCs) first.
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Topics

Accident, Error, and Injury Prevention

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