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Difficulty: HardAccident, Error, and Injury Prevention

While coordinating care on a busy neurology step-down unit, a registered nurse observes several activities occurring simultaneously. To prevent client injury, which situation requires the most immediate intervention by the nurse?

  1. A family member feeding thin liquids to a client with a recent ischemic stroke who is positioned at a 30-degree angleAnswer
  2. B
    A colleague entering the room of a client with disseminated varicella-zoster wearing a gown, gloves, and a standard surgical mask
  3. C
    A staff nurse applying bilateral soft wrist restraints to a confused client pulling at an IV line without first attempting to conceal the site
  4. D
    An unlicensed assistive personnel (UAP) independently completing the initial admission fall risk and skin assessments for a newly transferred client

Answer

The most immediate intervention is required for the family member feeding thin liquids to a stroke client positioned at a 30-degree angle, due to the imminent risk of aspiration.
The correct answer describes a situation that presents a direct and immediate threat to the client's airway (ABCs). A client with a recent stroke has a high likelihood of dysphagia. Feeding them thin liquids while improperly positioned (30 degrees instead of upright at 90 degrees) creates a severe and imminent risk for aspiration pneumonia or airway obstruction.

Step-by-Step Solution

1
Analyze each observation to identify the specific safety or procedural violation.
Observation 1 involves an aspiration risk; Observation 2 is an isolation precaution error; Observation 3 is a restraint protocol violation; Observation 4 is an improper delegation of assessment.
Identifying the specific error in each scenario is necessary to evaluate the potential harm to the clients.
2
Apply a prioritization framework, such as Maslow's Hierarchy of Needs or the ABCs (Airway, Breathing, Circulation).
The aspiration risk directly threatens the client's Airway and Breathing.
Prioritization frameworks guide nurses in determining which situation poses the most immediate threat to life.
3
Compare the severity and immediacy of the identified risks.
While infection control, restraint protocols, and proper delegation are critical to safe care, an immediate threat to the airway takes absolute precedence over all other issues.
Intervening in the situation that presents an imminent physiological threat prevents severe injury or death.

Key Concept

Accident, Error, and Injury Prevention through Prioritization
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Topics

Accident, Error, and Injury Prevention

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