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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse is implementing safety measures for a group of clients on a medical-surgical unit. Which nursing action best promotes client safety and injury prevention?

  1. Implementing a bed alarm and keeping the bed in the lowest position for a confused client who frequently attempts to wander.Answer
  2. B
    Elevating the head of the bed to 45 degrees for a client who returned one hour ago from a diagnostic lumbar puncture.
  3. C
    Applying soft wrist restraints to a mildly agitated client to prevent the removal of a peripheral intravenous catheter before attempting diversionary activities.
  4. D
    Delegating the initial environmental safety and fall risk assessment for a newly admitted client to an experienced unlicensed assistive personnel (UAP).

Answer

Implementing a bed alarm and keeping the bed in the lowest position for a confused client who frequently attempts to wander.
The correct answer demonstrates the appropriate use of fall prevention strategies. For a confused client at risk of wandering, utilizing a bed alarm and keeping the bed in the lowest position are evidence-based, least-restrictive interventions. These measures alert staff to potential falls without violating the client's autonomy or resorting to physical restraints.

Step-by-Step Solution

1
Analyze each option to identify which action represents a safe, evidence-based nursing intervention.
Three options describe unsafe practices or errors in judgment, while one describes a correct safety measure.
The question asks for the action that best promotes safety and injury prevention.
2
Evaluate the use of the bed alarm for a wandering client.
This is recognized as a safe, least-restrictive alternative to physical restraints that effectively mitigates fall risk.
Maintaining the bed in the lowest position and using alarms align with standard fall prevention guidelines.
3
Identify the safety violations in the remaining choices.
Elevating the head of the bed post-lumbar puncture risks a spinal headache; using restraints without trying alternatives violates restraint protocols; and delegating an initial assessment violates the nursing scope of practice.
Understanding contraindicated positioning, strict restraint guidelines, and the RN scope of practice is essential for comprehensive error prevention.

Key Concept

Identifying and implementing least restrictive safety measures while avoiding common procedural and delegation errors.
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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