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Zorluk: Çok zorAccident, Error, and Injury Prevention

An older adult client with bilateral macular degeneration and right-sided profound hearing loss is recovering on the surgical unit 48 hours after a right femoral-popliteal bypass graft. The client is currently receiving scheduled oral opioid analgesics. To maintain a safe care environment and prevent injury, which interventions should the practical nurse (PN) incorporate into the plan of care? Select all that apply.

  1. Approach the client from the left side and announce presence clearly before initiating any physical contact.Cevap
  2. B
    Maintain all four bed side rails in the elevated position whenever the client is resting to prevent unassisted ambulation.
  3. Position the bedside table with the call light, water pitcher, and frequently used personal items on the client's left side.Cevap
  4. D
    Instruct the unlicensed assistive personnel (UAP) to evaluate whether the client's current mobility status warrants a bed alarm.
  5. E
    Document any sudden onset of nighttime disorientation as an expected age-related cognitive change associated with unfamiliar environments.
  6. Verify that the pathway from the bed to the bathroom is continuously illuminated with a nightlight and kept entirely free of clutter.Cevap

Cevap

The correct interventions are approaching the client from the left side, positioning the bedside table on the left side, and verifying the pathway to the bathroom is continuously illuminated.
The correct interventions synthesize the client's unique sensory deficits and surgical recovery needs to minimize injury risk. Approaching from the left utilizes the intact left ear and peripheral vision, preventing a startle response. Placing items on the left side accommodates the hearing loss and prevents the client from twisting over the operative right leg, protecting the surgical graft. Ensuring continuous, clear pathway illumination directly mitigates the high fall risk associated with impaired central vision and contrast sensitivity.

Adım Adım Çözüm

1
Analyze the client's specific physical, sensory, and pharmacological risk factors.
The client has impaired central vision, profound right-sided hearing loss, restricted mobility from a right leg surgical graft, and is taking sedating opioids.
Identifying overlapping vulnerabilities is necessary to tailor specific, effective safety interventions.
2
Evaluate each proposed intervention against the client's deficits and current nursing standards.
Interventions must safely accommodate the left-sided sensory strengths, protect the right leg graft, avoid unauthorized restraints, and adhere to proper delegation guidelines.
Safety measures must be clinically appropriate, within scope of practice, and not inadvertently increase the risk of injury.
3
Select the appropriate actions that safely prevent injury.
Approaching from the left, keeping items on the left, and ensuring illuminated pathways are the correct actions.
These actions directly mitigate the client's unique fall and injury risks without violating legal or ethical nursing standards.

Anahtar Kavram

Accident, Error, and Injury Prevention in clients with complex sensory and physical deficits
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Konular

Accident, Error, and Injury Prevention

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