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Zorluk: OrtaAccident, Error, and Injury Prevention

A registered nurse is implementing a safety plan for an older adult client who is confused, frequently attempts to get out of bed unassisted, and is receiving a continuous intravenous (IV) infusion. Which actions by the nurse are appropriate to prevent injury and errors? Select all that apply.

  1. Place the client in a room close to the nurses' station to facilitate frequent visual checks.Cevap
  2. B
    Apply bilateral soft limb restraints immediately to prevent the client from pulling out the IV catheter.
  3. C
    Delegate the ongoing evaluation of the client's mental status to the unlicensed assistive personnel (UAP).
  4. Camouflage the IV tubing and insertion site by covering the arm with a stockinette.Cevap
  5. Keep the client's bed in the lowest position with the bed exit alarm activated.Cevap
  6. F
    Administer a prescribed secondary intravenous medication concurrently with the primary infusion after confirming both fluids appear clear.

Cevap

The appropriate actions are placing the client in a room close to the nurses' station, camouflaging the IV tubing with a stockinette, and keeping the bed in the lowest position with the alarm activated.
The appropriate actions prioritize non-restrictive safety measures and fall prevention. Moving the client closer to the nurses' station increases surveillance. Camouflaging the IV line is a recognized restraint alternative that reduces visual stimulation to pull at the line. Keeping the bed low and using an alarm minimizes the injury risk if the client attempts to stand.

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1
Identify the primary risks for this specific client.
The client is at high risk for falls (due to confusion and unassisted bed exits) and potential injury from dislodging the IV line.
Recognizing specific hazards dictates which safety interventions are required.
2
Evaluate interventions for fall prevention.
Maintaining the bed in the lowest position with alarms activated and placing the client close to the nurses' station for frequent observation are correct, evidence-based practices.
These measures increase surveillance and minimize the distance to the floor, reducing the likelihood and severity of a fall.
3
Evaluate interventions for IV line protection.
Camouflaging the insertion site is a valid, non-restrictive alternative to prevent line pulling. Immediate restraint application is incorrect.
Safety protocols mandate that restraints are a measure of last resort; non-restrictive alternatives must be attempted and documented first.
4
Evaluate delegation and medication administration practices.
Assessing mental status cannot be delegated to UAP. IV fluid compatibility must be verified with a reference guide, not by visual clarity alone.
Ongoing evaluation requires nursing clinical judgment. Visual clarity does not rule out microscopic precipitation or chemical incompatibility.

Anahtar Kavram

Implementing a comprehensive safety plan for a confused client requires maximizing non-restrictive interventions, ensuring appropriate delegation of tasks, and adhering strictly to medication administration protocols.
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Accident, Error, and Injury Prevention

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