A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)

Question

a. Leave the stretcher in the lowest position with rails down so that the client can access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential medical information.
e. Isolate clients who have immune suppression disorders to prevent hospital-acquired infections.

Answer 1

ANS: B, C, D
To ensure client and staff safety, nurses should use two identifiers per The Joint Commission's National Patient Safety Goals; follow the hospital's security plan, including de-escalation strategies for people who demonstrate aggressive or violent tendencies; and search belongings to identify essential medical information. Nurses should also use standard fall prevention interventions, including leaving stretchers in the lowest position with rails up, and isolating clients who present with signs and symptoms of contagious infectious disorders.