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Zorluk: OrtaAccident, Error, and Injury Prevention

A client with a continuous intravenous (IV) infusion is scheduled for transport to the radiology department. The client appears restless and repeatedly grasps at the IV tubing. Which actions should the practical nurse implement to prevent accidental dislodgement and maintain a safe environment? (Select all that apply.)

  1. Obscure the IV insertion site by wrapping it loosely with a conforming bandage or stockinette.Cevap
  2. B
    Apply bilateral soft wrist restraints to secure the client's hands during the transport process.
  3. Provide a textured item, such as a folded washcloth, for the client to hold in the unaffected hand.Cevap
  4. D
    Instruct the transport personnel to silence and adjust the IV pump infusion rate if an occlusion alarm sounds.
  5. Arrange for an unlicensed assistive personnel (UAP) to ride along and sit directly beside the client.Cevap

Cevap

The correct interventions are obscuring the IV site, providing a sensory diversion item, and assigning a UAP to accompany the client.
The correct actions focus on prioritizing client safety using least-restrictive methods and appropriate delegation. Obscuring the IV site removes the visual trigger, providing a washcloth offers a safe sensory distraction for restless hands, and having a UAP accompany the client ensures immediate supervision and redirection.

Adım Adım Çözüm

1
Analyze the client's behavior and the risk presented.
The client is restless and grasping at the IV tubing, creating a high risk for accidental dislodgement and subsequent injury or bleeding.
Identifying the specific safety hazard dictates the necessary interventions.
2
Evaluate the proposed interventions against the principle of least restrictive restraints.
Applying wrist restraints is a restrictive measure and a last resort. Hiding the site, providing a distraction, and using a sitter are least-restrictive alternatives.
Nursing standards require attempting and documenting least-restrictive alternatives before utilizing physical restraints.
3
Evaluate the delegation and assignment aspects of the interventions.
Assigning a UAP to sit with the client is an appropriate delegation of a routine safety task. However, delegating the adjustment of an IV pump to transport personnel is outside their scope of practice.
The practical nurse must only delegate tasks that fall within the receiver's scope of practice and training to ensure client safety.

Anahtar Kavram

Implementing least restrictive alternatives and appropriate delegation to maintain client safety.
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Konular

Accident, Error, and Injury Prevention

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