NUR 02

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? 1. UAP has attached a bed alarm to the client's gown and bed 2. UAP has been making hourly rounds on the client 3. UAP has lowered the bed and raised all 4 side rails 4. UAP has placed a fall risk ID bracelet on the client's wrist Explanation: Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. (Option 1) Placing a bed alarm would be an appropriate intervention for this client. (Option 2) Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. (Option 4) Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls. Educational objective: The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client. 2-Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first? 1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake 2. Room 2: Client and family request clergy to administer last rites 3. Room 3: Puncture-resistant sharps disposal container on the wall is full 4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4 mmol/L) Explanation: Health care workers are required to abide by Occupational Safety and Health Administration standards and regulations to reduce work-related injuries (eg, sharps) and exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container should not be overfilled and should be replaced on a regular basis to reduce the risk for a needle stick during disposal. (Option 1) If any urine is discarded by accident during a 24-hour collection test, the procedure must be restarted. A new container will need to be labeled with the appropriate times and date, but immediate intervention is not required.