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Zorluk: OrtaAccident, Error, and Injury Prevention

A clinical nurse educator is observing staff members delivering care on a medical-surgical unit. Which observation requires the educator to intervene immediately to prevent client injury?

  1. A
    A licensed practical nurse (LPN) donning a disposable gown and clean gloves prior to entering the room of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection
  2. B
    A registered nurse securing bilateral soft wrist restraint straps to the movable portion of the bed frame using a quick-release knot
  3. An unlicensed assistive personnel (UAP) elevating the head of the bed to 60 degrees for a client who returned from a right femoral cardiac catheterization 90 minutes agoCevap
  4. D
    An unlicensed assistive personnel (UAP) assisting a clinically stable client who is receiving a continuous intravenous infusion of 0.9% sodium chloride to ambulate in the hallway

Cevap

The educator must intervene immediately when observing the UAP elevating the head of the bed to 60 degrees for a client who is recently post-cardiac catheterization via the femoral artery.
The observation of a staff member elevating the head of the bed to 60 degrees for a client recently post-cardiac catheterization via the femoral artery requires immediate intervention. Following a femoral approach, the client's affected leg must remain straight, and the head of the bed should generally be kept flat or elevated no more than 30 degrees (per facility protocol) for several hours. Flexion of the hip drastically increases stress on the fresh arterial puncture site, creating a high risk for arterial bleeding and hematoma formation.

Adım Adım Çözüm

1
Analyze the observation regarding the post-cardiac catheterization client.
Elevating the head of the bed to 60 degrees causes significant hip flexion.
Following a femoral approach, hip flexion increases stress on the arterial puncture site, creating an immediate and high risk for severe bleeding and hematoma formation. This requires urgent intervention.
2
Evaluate the restraint application observation.
Securing restraints to the movable bed frame with a quick-release knot is standard safety protocol.
This safe practice ensures the restraints do not tighten if the bed is repositioned and allows for rapid removal during an emergency.
3
Assess the infection control observation for the client with MRSA.
Donning a gown and gloves is the correct personal protective equipment (PPE) for contact precautions.
This safe practice prevents the transmission of multi-drug resistant organisms.
4
Evaluate the delegation of ambulation to the UAP.
Ambulating a stable client with a continuous peripheral IV is within the UAP's scope of practice.
Because the client is clinically stable and the task does not require nursing assessment, this is a safe and appropriate delegation.
5
Identify the action that poses an immediate threat to client safety.
The UAP elevating the bed of the cardiac catheterization client is the only unsafe action observed.
It is the only action that will directly and immediately compromise client physiological integrity.

Anahtar Kavram

Following a femoral cardiac catheterization, the client must remain flat or with the head of the bed elevated no more than 30 degrees (depending on facility policy) with the affected extremity kept straight to prevent life-threatening arterial hemorrhage.
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Konular

Accident, Error, and Injury Prevention

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