A newly licensed nurse is obtaining consent for a surgical procedure.
Which action by the newly licensed nurse is most appropriate?

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

Choice A rationale:

The nurse mistakenly calling the patient's daughter "your wife" is a communication error but does not qualify as a sentinel event. Sentinel events are serious, largely preventable patient safety incidents that result in significant harm or death to the patient. Miscommunication, while important to address, does not fall under the category of a sentinel event.

Choice B rationale:

A surgical procedure performed on the wrong leg of a patient is a classic example of a sentinel event. Wrong-site surgery is a serious medical error that can lead to severe consequences for the patient. Proper protocols and procedures, such as time-outs and site marking, are in place to prevent such incidents, making this a sentinel event that requires immediate investigation and analysis to prevent recurrence.

Choice C rationale:

The surgical procedure being postponed by 30 minutes, while potentially inconvenient, does not constitute a sentinel event. Delays in surgical schedules are not uncommon due to various reasons such as emergencies or the complexity of preceding procedures. While delays should be minimized, they do not necessarily result in patient harm or death, making them different from sentinel events.

Choice D rationale:

The nurse failing to raise the bed to a working height during patient care is a safety concern but does not qualify as a sentinel event. It is important for nurses to adhere to proper body mechanics and safety protocols to prevent accidents and injuries. While this situation requires correction and education, it does not meet the criteria of a sentinel event.