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Zorluk: ZorAccident, Error, and Injury Prevention

Following an open reduction and internal fixation of the right femur, a 74-year-old client suddenly exhibits new-onset severe agitation. The client, who was previously oriented and cooperative, begins attempting to climb over the raised side rails and forcefully pulls off the continuous pulse oximeter. Which action should the practical nurse (PN) take first to prevent client injury?

  1. Remain at the bedside, activate the bed alarm system, and instruct an assistive personnel to notify the registered nurse (RN)Cevap
  2. B
    Secure bilateral soft wrist restraints to prevent the client from removing the medical equipment and falling from the bed
  3. C
    Prepare and administer the prescribed as-needed intravenous (IV) push lorazepam to rapidly manage the acute agitation
  4. D
    Document the confusion as an expected transient reaction to anesthesia and dim the lights to promote a calming environment

Cevap

The priority action is to remain at the bedside, activate the bed alarm system, and instruct an assistive personnel to notify the registered nurse (RN).
Staying at the bedside and using a bed alarm provides immediate client safety through the least restrictive means. By delegating the task of notifying the RN to another staff member, the PN ensures that the acute change in condition is appropriately escalated for advanced assessment without leaving the client alone in a dangerous situation.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is exhibiting sudden, new-onset agitation and attempting to get out of bed, indicating a high fall risk and a potential acute physiological complication (e.g., hypoxia, delirium).
Recognizing the difference between expected postoperative behavior and acute clinical deterioration is required to implement appropriate safety measures.
2
Identify the immediate safety needs.
The client requires continuous supervision to prevent a fall, meaning the PN must not leave the room.
Leaving an agitated, high-fall-risk client alone to seek help significantly increases the likelihood of a major injury.
3
Determine the least restrictive, within-scope intervention.
Activating a bed alarm and staying with the client provides immediate safety without using unauthorized restraints, while delegating the notification task to assistive personnel ensures the RN is alerted.
Client safety protocols dictate that less restrictive alternatives must be utilized before physical or chemical restraints, and acute changes must be assessed by the RN.

Anahtar Kavram

Accident, Error, and Injury Prevention: Least Restrictive Interventions and Scope of Practice
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Konular

Accident, Error, and Injury Prevention

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