A practical nurse (PN) is caring for a client with a history of intravenous substance use disorder who is receiving intravenous (IV) antibiotics. Upon entering the client's room, the PN observes the client actively attempting to inject an unknown clear liquid from a syringe directly into the peripheral IV line port. Arrange the following PN actions in the correct order of priority.
- 1Verbally direct the client to stop the injection and immediately clamp the intravenous tubing.
- 2Don gloves and safely secure the syringe out of the client's reach.
- 3Perform a focused assessment of the client's airway, breathing, circulation, and neurological status.
- 4Report the incident and assessment findings to the charge nurse and the healthcare provider.
- 5Document the event objectively in the medical record and complete a facility incident report.
Cevap
The correct priority sequence is: 1. Clamp the IV tubing, 2. Secure the syringe, 3. Assess the client's physiological status, 4. Notify the RN and healthcare provider, 5. Document the event.
In acute situations involving high-risk behaviors and imminent danger, the nurse must prioritize interventions using Maslow's hierarchy of needs and fundamental safety principles. The immediate priority is to stop the physiological threat (clamping the IV). Next, the nurse secures the environment to prevent further harm. Once the scene is safe, the nurse collects data by assessing the client's current physiological status. This crucial assessment data is then communicated to the RN and healthcare provider to guide collaborative management. Finally, the nurse completes the legal and administrative requirement of documentation.
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Prioritization of Care: Acute High-Risk Behaviors