The practical nurse (PN) is conducting a routine safety audit on a medical-surgical unit. Which observation requires the PN to immediately intervene to prevent a potential client injury or adverse event?
- A client who is newly agitated is placed in physical wrist restraints before any less restrictive interventions are attempted.Cevap
- BAn unlicensed assistive personnel (UAP) removes their contaminated gloves before untying and removing their isolation gown.
- CA newly licensed PN accepts a delegated assignment to administer routine oral medications to a clinically stable client.
- DA staff member notifies the healthcare provider about an older adult client who developed sudden, unexpected disorientation during the shift.
Cevap
A client who is newly agitated is placed in physical wrist restraints before any less restrictive interventions are attempted.
Applying physical restraints should always be a measure of last resort. The standard of care requires that less restrictive alternative measures (such as frequent reorientation, decreasing environmental stimulation, offering a diversion, or involving a sitter) must be attempted and documented before restraints are utilized to prevent injury, skin breakdown, and psychological distress. Observing this premature application of restraints requires immediate intervention by the PN.
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Anahtar Kavram
Accident, Error, and Injury Prevention: Restraint Alternatives and Safety Practices