A practical nurse (PN) conducts a routine room check at a residential substance use treatment facility and discovers a client preparing to swallow a handful of unidentified pills. Arrange the following PN actions in the correct order of priority.
- 1Direct the client to stop and safely intervene to prevent ingestion.
- 2Confiscate the unidentified pills and secure them out of the client's reach.
- 3Collect data regarding the client's vital signs and level of consciousness.
- 4Report the incident and the client's physiological status to the registered nurse (RN).
- 5Document the behavioral event, assessment findings, and interventions in the medical record.
Cevap
The correct sequence is to first prevent ingestion, then secure the pills, collect client data, notify the RN, and finally document the event.
In any acute safety crisis involving high-risk behavior, the practical nurse must follow standard safety prioritization frameworks. The absolute first action is to stop immediate harm (preventing ingestion). The second is to secure the environment (removing the pills). Third, the nurse collects data to determine the client's current physiological status. Fourth, this data is reported to the RN or provider for further orders. Finally, the entire incident is documented in the medical record.
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Anahtar Kavram
Prioritization in acute behavioral and safety incidents requires immediate harm reduction, followed by hazard removal, data collection, reporting, and documentation.