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Question

Difficulty: HardAccident, Error, and Injury Prevention

While coordinating care on a busy acute care unit, a registered nurse observes several activities being performed by the healthcare team. Which observed action poses the greatest immediate risk to client safety and necessitates an urgent intervention?

  1. Lowering a client to a flat, supine position for a bed bath while a continuous enteral tube feeding is actively infusing.Answer
  2. B
    Securing a client's prescribed soft wrist restraints directly to the bed's side rails to allow for quick release in an emergency.
  3. C
    Wearing a standard surgical mask, gown, and gloves when providing care for a client diagnosed with disseminated herpes zoster.
  4. D
    Delegating the initial set of vital signs to the unlicensed assistive personnel (UAP) for a client who just started a new intravenous (IV) antibiotic.

Answer

Lowering a client to a flat, supine position for a bed bath while a continuous enteral tube feeding is actively infusing.
All of the observed actions represent safety errors, but lowering the head of the bed while a continuous enteral feeding is running is the highest priority because it creates an immediate, severe risk for aspiration (Airway/Breathing). The infusion pump must always be paused before the bed is flattened for any reason.

Step-by-Step Solution

1
Analyze the stem's requirement.
The question asks to identify the action posing the 'greatest immediate risk,' requiring the application of prioritization frameworks like ABCs (Airway, Breathing, Circulation).
When multiple unsafe actions are presented, the nurse must intervene first on the one that causes immediate physiological harm.
2
Evaluate the risk of lowering the bed during active enteral feeding.
Identified as a direct threat to the airway due to high risk of gastric reflux and aspiration.
Aspiration compromises breathing and oxygenation immediately.
3
Evaluate the remaining options against the ABC framework.
Restraints on side rails (injury risk), surgical mask for airborne pathogen (transmission risk), and delegating initial vitals (potential delayed reaction recognition) are all safety errors, but lack the immediate, guaranteed physiological compromise of an actively unprotected airway.
Airway and breathing threats always take clinical precedence over infection control, potential injuries, or assessment delays.

Key Concept

When confronted with multiple safety hazards or procedural errors, the nurse must prioritize interventions based on the ABCs (Airway, Breathing, Circulation); actively infusing enteral feedings while supine poses an immediate airway threat.
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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