Examkin

Soru

Zorluk: ZorAccident, Error, and Injury Prevention

A newly admitted client with a history of severe osteoporosis and bilateral cataracts is starting a prescribed loop diuretic regimen. The client has limited mobility and uses a rolling walker. Which actions are appropriate for the practical nurse (PN) to take regarding this client's safety and care? (Select all that apply.)

  1. Position a bedside commode directly adjacent to the bed on the client's strongest side.Cevap
  2. Activate a weight-sensitive bed exit alarm to provide early warning if the client attempts to ambulate unassisted.Cevap
  3. Place the client's eyeglasses, call light, and personal items within their immediate physical and visual reach.Cevap
  4. D
    Keep all four bed side rails in the raised and locked position while the client is sleeping to prevent falls.
  5. E
    Document any sudden onset of nighttime disorientation as an expected, age-related cognitive transition.
  6. F
    Accept the delegation to independently formulate and establish the client's initial comprehensive safety care plan.

Cevap

The appropriate actions are positioning a bedside commode nearby, activating a weight-sensitive bed exit alarm, and keeping the client's essential items within immediate physical and visual reach.
The correct actions focus on mitigating the client's specific risks while maintaining a safe, least-restrictive environment. Positioning a bedside commode addresses the urinary urgency caused by the loop diuretic, minimizing the distance the client must ambulate. Placing items within immediate reach accommodates the client's bilateral cataracts and prevents overreaching, which could lead to a fall. Activating a bed exit alarm provides a safe, non-restrictive alternative to physical restraints, alerting staff if the high-risk client attempts to get up unassisted.

Adım Adım Çözüm

1
Analyze the client's clinical profile and identified risk factors.
The client has high fall and injury risks compounded by osteoporosis (fragile bones), cataracts (impaired vision), and a loop diuretic (which causes urinary urgency and frequency).
Identifying specific physiological and pharmacological risk factors is the first step in formulating targeted safety interventions.
2
Select interventions that safely address the identified risks without exceeding the PN scope of practice.
Safe interventions include placing a commode near the bed, keeping items within visual reach, and using a bed alarm.
These actions directly mitigate the risks of urinary urgency and visual impairment while providing safe monitoring.
3
Identify and eliminate actions that represent unsafe practices or scope violations.
Raising four side rails, dismissing sudden confusion as normal, and independently establishing the initial care plan are identified as inappropriate.
Four side rails act as a physical restraint, sudden confusion indicates acute delirium requiring investigation, and establishing the initial care plan requires RN-level clinical judgment.

Anahtar Kavram

Comprehensive injury prevention for high-risk clients requires non-restrictive safety measures, environmental modifications tailored to sensory deficits, and strict adherence to the PN scope of practice.
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru