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Zorluk: OrtaAccident, Error, and Injury Prevention

A nurse receives the shift handoff report for four clients on a medical-surgical unit. Which client should the nurse assess first to prevent a potential injury or adverse event?

  1. A client with acute confusion who is wandering the hallway and actively pulling at their peripheral intravenous (IV) line.Cevap
  2. B
    A client with a documented high fall risk who has an activated bed alarm and is requesting assistance to use the bedside commode.
  3. C
    A client with dysphagia requiring aspiration precautions whose meal tray delivery and setup has been delegated to the unlicensed assistive personnel (UAP).
  4. D
    A client on contact precautions for an active infection who is pacing independently inside their closed, private room.

Cevap

The client with acute confusion who is wandering the hallway and actively pulling at their peripheral intravenous (IV) line.
The client who is confused, wandering, and pulling at an IV line requires immediate assessment because they are actively engaging in unsafe behavior without supervision. This situation presents a high, immediate risk for falls, bleeding, and loss of essential intravenous access.

Adım Adım Çözüm

1
Analyze the immediate safety risk of each client based on the ABCs and Maslow's hierarchy of needs.
Identify which client presents the most immediate threat to their own physical safety or the safety of others.
Prioritization requires addressing acute, unmitigated risks before addressing stable or protected clients.
2
Evaluate the confused, wandering client.
Determine that this client is unmonitored and actively engaging in behavior that could immediately lead to a fall, bleeding, or loss of essential IV access.
Wandering with an IV line presents an acute, real-time safety hazard that requires immediate de-escalation and intervention.
3
Compare the acute risk of the wandering client to the remaining clients.
Conclude that the other clients either have safety measures in place (an activated bed alarm), are appropriately delegated for non-clinical tasks (meal setup), or are maintaining safety within their room boundaries (pacing in isolation).
The other situations are either stable or represent a lower acuity of risk compared to the unmonitored, confused client.

Anahtar Kavram

Prioritization of Client Safety and Injury Prevention
Tahmini Süre:1m 0s
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Konular

Accident, Error, and Injury Prevention

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