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Question

Difficulty: HardAccident, Error, and Injury Prevention

A preceptor is evaluating a newly licensed nurse on the implementation of clinical safety protocols in a medical-surgical unit. Which of the following actions by the newly licensed nurse demonstrate correct adherence to safety guidelines? (Select all that apply.)

  1. Verifying a client's identity by asking them to state their full name and date of birth while comparing it to the identification band and medication record.Answer
  2. B
    Delegating the initial assessment and vital sign measurement of a client who just arrived from the post-anesthesia care unit to the unlicensed assistive personnel (UAP).
  3. Utilizing a specialized enteral syringe with a non-Luer tip to administer prescribed liquid medications through a client's gastrostomy tube.Answer
  4. D
    Applying prescribed soft wrist restraints to a highly agitated client who is pulling at their intravenous line before attempting to use a protective sleeve.
  5. E
    Instructing family members to use an alcohol-based hand rub upon exiting the room of a client who is isolated for an active Clostridioides difficile infection.
  6. Discarding the remaining portion of a single-dose vial of a controlled substance in a designated receptacle while a second licensed nurse observes the process.Answer

Answer

The correct actions that adhere to safety protocols are verifying the client's identity using two active identifiers, utilizing non-Luer tip syringes for enteral tubes, and having a second nurse witness and document the wasting of a controlled substance.
Adhering to safety guidelines requires active patient identification (having the client state their name and date of birth) to prevent wrong-patient errors. Using enteral-specific syringes with non-Luer tips is critical to prevent accidental intravenous administration of enteral fluids. Finally, wasting controlled substances requires a witness by a second licensed nurse to prevent diversion and ensure safety compliance.

Step-by-Step Solution

1
Analyze the scenario to determine the focus of the question.
The question asks to identify nursing actions that correctly implement safety protocols and prevent errors or injuries.
Differentiating between safe and unsafe clinical practices is essential for medical error mitigation and environmental safety.
2
Evaluate the actions regarding patient identification and medication preparation.
Asking the client to actively state their name and using a non-Luer syringe for enteral medications are both correct safety practices.
These actions directly prevent wrong-patient and wrong-route administration errors.
3
Evaluate the actions involving delegation, restraints, and infection control.
Delegating an initial assessment, applying restraints before trying alternatives, and using alcohol rub for C. diff are unsafe practices.
Initial assessments are strictly the RN's responsibility; restraints require prior exhaustion of alternatives; and C. diff spores require soap and water.
4
Evaluate the action regarding controlled substances.
Wasting a controlled substance with a licensed witness is a correct safety practice.
It prevents medication diversion and complies with institutional safety standards.

Key Concept

Accident, Error, and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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