A clinical nurse educator is conducting a safety audit on a critical care step-down unit. The educator observes a newly hired registered nurse (RN) managing a critically ill client who has active pulmonary tuberculosis, hyperactive delirium, and requires a continuous central venous infusion. Which observed actions by the newly hired RN represent a breach of safety protocols requiring immediate intervention? Select all that apply.
- Applying physical wrist restraints as the primary intervention upon noting the client tugging at the intravenous dressingCevap
- Propping the door to the negative-pressure isolation room slightly ajar to maintain a direct line of sightCevap
- Delegating the initial assessment of the client's bilateral radial pulses and skin integrity to the unlicensed assistive personnelCevap
- Administering an intravenous push anxiolytic through the Y-site of a continuous parenteral nutrition infusion without consulting a compatibility referenceCevap
- ESecuring a standard surgical mask over the client's nose and mouth prior to transporting them to the radiology department
- FDoffing the N95 particulate respirator in the hallway immediately after exiting the isolation room and securing the door
Cevap
The actions requiring intervention are applying restraints without attempting alternatives, propping the isolation room door open, delegating initial assessments to unlicensed assistive personnel, and administering intravenous push medications into a parenteral nutrition line without verifying compatibility.
These four actions represent critical safety violations. Physical restraints must only be applied after less restrictive alternatives have failed. Airborne precautions strictly require the door to remain completely closed to maintain negative pressure. Initial assessments require nursing clinical judgment and cannot be delegated to unlicensed assistive personnel. Lastly, parenteral nutrition is highly incompatible with many drugs, making compatibility verification essential before co-administration to prevent life-threatening precipitation.
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Anahtar Kavram
Comprehensive client safety requires integrating strict infection control protocols, adherence to the nursing process for delegation, mandatory verification of intravenous compatibilities, and utilizing the least restrictive means for managing delirium.