A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?

Explanation

A. Turn cellular phones to silent mode

Staff members should be advised to silence their cellular phones during an active shooter situation. This helps maintain silence and prevents the ringing or vibrating of phones from potentially revealing the location of individuals hiding or seeking shelter.

Move wounded clients to a safe area before finding shelter in (option B) is not correct. In the event of an active shooter situation. The safety of both staff members and clients is paramount. If it can be done quickly and without putting oneself or others at significant risk, moving wounded clients to a safe area before finding shelter may be advisable. However, the primary focus should be on finding shelter and protecting oneself from harm.

Attempt to bargain with the shooter in (option C) is not correct. Engaging in negotiations or attempting to reason with an active shooter can be extremely dangerous and may escalate the situation. Staff members should be instructed to prioritize their own safety and follow established active shooter protocols, which often involve evacuating, hiding, or acting to incapacitate or disable the shooter as a last resort.

Wave hands to attract the attention of law enforcement in (option D) is not correct. Waving hands or making sudden movements that may be misconstrued as threatening can potentially result in harm or confusion when law enforcement or security personnel are responding to an active shooter situation. It is important to follow their instructions calmly and clearly, keeping hands visible and following their guidance to ensure everyone's safety.

In summary, the nurse should recommend turning cellular phones to silent mode, moving wounded clients to a safe area if possible, not attempting to bargain with the shooter, and avoiding actions that may be misinterpreted by law enforcement. These recommendations are aimed at prioritizing personal safety and following established protocols to minimize risks during an active shooter situation.

An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.

In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.

The other examples listed may require further actions but may not necessarily require an incident report:

1. A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
2. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
3. A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.