During a shift assessment, a registered nurse evaluates a client who is receiving a continuous intravenous (IV) heparin infusion for a deep vein thrombosis. The client, who has a history of stroke with residual dysphagia, is additionally on contact precautions for a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse notes the client has become acutely disoriented, highly agitated, and is repeatedly attempting to climb out of bed unassisted. Which of the following interventions should the nurse implement to maintain a safe care environment? Select all that apply.
- Transfer the client to a private room that offers direct visibility from the nursing station.Cevap
- Enable a bed-exit alarm system to alert the healthcare team of unassisted movement.Cevap
- Ensure that oral suction equipment is assembled and functioning at the bedside.Cevap
- DInstruct the unlicensed assistive personnel (UAP) to conduct a swallowing assessment before providing a meal tray.
- ERequest a prescription for physical restraints to prevent the client from removing the continuous IV line.
- FDon a particulate respirator mask (e.g., N95) prior to entering the client's room to prevent the spread of infection.
Cevap
The correct actions are transferring the client to a visible private room, enabling a bed-exit alarm, and ensuring suction equipment is available.
For a confused, agitated client with a high risk of falls and aspiration, safety is maximized by implementing non-restrictive monitoring strategies and ensuring emergency equipment is prepared. Relocating the client for better visibility and utilizing bed alarms are primary restraint alternatives that allow for rapid staff intervention. Furthermore, keeping functional suction equipment at the bedside is a critical airway protection measure for any client with known dysphagia.
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Anahtar Kavram
Prioritizing client safety through restraint alternatives, appropriate delegation, and precise infection control.