Examkin

Soru

Zorluk: OrtaAccident, Error, and Injury Prevention

A practical nurse is caring for an older adult client who requires continuous supplemental oxygen via a nasal cannula. The client is increasingly restless and repeatedly removes the oxygen tubing from their nares, causing their oxygen saturation to drop. Which action should the nurse take first to maintain safety and prevent injury?

  1. Provide a tactile diversion, such as a folded washcloth, for the client to hold and manipulate.Cevap
  2. B
    Apply bilateral soft wrist restraints to physically block the client from reaching the cannula.
  3. C
    Document the restlessness as an expected age-related change and leave the tubing off until the client sleeps.
  4. D
    Prepare to administer a PRN intravenous (IV) push sedative to rapidly calm the client's agitation.

Cevap

Provide a tactile diversion, such as a folded washcloth, for the client to hold and manipulate.
The correct action demonstrates adherence to the principle of using the least restrictive alternative. By giving the client a safe object to hold, the nurse redirects the restless behavior and occupies the client's hands, thereby protecting the airway equipment without violating the client's autonomy or safety.

Adım Adım Çözüm

1
Assess the client's immediate safety need.
The client is experiencing dropping oxygen saturation due to repeatedly removing the nasal cannula.
Identifying the root cause of the risk (pulling at the tubing due to restlessness) is required to select an appropriate intervention.
2
Determine the least restrictive intervention.
The nurse selects a tactile diversion to keep the client's hands occupied.
Nursing standards mandate that non-pharmacological, least-restrictive alternatives must be attempted before physical or chemical restraints are used.

Anahtar Kavram

Least Restrictive Alternatives and Injury Prevention
Bu soruyu puanla

Konular

Accident, Error, and Injury Prevention

Bu konudan daha fazla soru