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Question

Difficulty: HardAccident, Error, and Injury Prevention

A client undergoing treatment for severe pneumonia is on the second day of hospitalization and begins displaying coarse tremors, diaphoresis, and severe agitation. The client repeatedly attempts to remove their peripheral intravenous (IV) catheter. With the registered nurse (RN) temporarily unavailable, which action should the practical nurse (PN) take first to protect the client from self-injury?

  1. Request an unlicensed assistive personnel (UAP) to provide continuous one-to-one bedside observation.Answer
  2. B
    Apply bilateral soft wrist restraints to prevent the client from reaching the IV insertion site.
  3. C
    Retrieve and administer a prescribed as-needed intravenous (IV) push dose of a sedative.
  4. D
    Stand near the client and logically explain the importance of maintaining the IV access for their recovery.

Answer

Request an unlicensed assistive personnel (UAP) to provide continuous one-to-one bedside observation.
Providing a bedside sitter (UAP) is a safe, effective, and least restrictive alternative to physical restraints. It falls within the PN's scope of practice to delegate this monitoring task, ensuring the client's immediate safety from self-injury while the RN is unavailable. This intervention addresses the immediate hazard without violating restraint protocols or exceeding practice boundaries.

Step-by-Step Solution

1
Assess the client's immediate safety risk and level of agitation.
The client is at high risk for self-injury by dislodging the IV catheter due to altered mental status and agitation.
Identifying the immediate threat guides the selection of the most appropriate and least restrictive intervention.
2
Evaluate available interventions within the practical nurse (PN) scope of practice.
The PN must select a safe, non-invasive method to protect the IV line while adhering to the principle of least restrictive restraints.
Nurses are legally and ethically required to use alternatives before applying physical or chemical restraints.
3
Implement the least restrictive safety measure.
A UAP is assigned to sit with the client to provide continuous monitoring and redirection.
One-to-one observation ensures immediate safety without violating restraint protocols or exceeding the PN's scope of practice.

Key Concept

Accident, Error, and Injury Prevention (Restraint Alternatives and Scope of Practice)
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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