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Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client who is receiving treatment for a urinary tract infection exhibits new-onset restlessness, frequently attempts to climb out of bed unassisted, and is persistently picking at a peripheral intravenous (IV) insertion site. Which actions should the practical nurse implement to promote client safety? Select all that apply.

  1. Apply a tubular elastic dressing over the IV site to obscure it from the client's vision.Answer
  2. Move the client to a room with a direct line of sight from the nursing station.Answer
  3. Offer the client a manipulative activity apron or a washcloth to fold.Answer
  4. D
    Request a prescription for soft bilateral wrist restraints to maintain the integrity of the IV access.
  5. E
    Reassure the family that the sudden onset of confusion is an expected age-related change.
  6. F
    Administer a prescribed as-needed (PRN) intravenous (IV) push sedative to manage the client's severe restlessness.

Answer

The correct actions are applying a tubular elastic dressing over the IV site, moving the client to a room closer to the nursing station, and offering a manipulative activity.
The client is experiencing acute confusion and demonstrating behaviors that increase the risk of injury. The practical nurse must prioritize least-restrictive interventions to ensure safety. Obscuring the IV site removes the visual trigger for pulling. Moving the client closer to the nurses' station allows for frequent monitoring without the use of physical restraints. Providing a manipulative activity offers a safe distraction for restless hands, reducing the likelihood of medical device dislodgment.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has acute, new-onset restlessness and confusion associated with an infection, which increases the risk for falls and IV dislodgment.
Identifying the root cause and specific safety risks dictates the appropriate interventions.
2
Evaluate potential safety interventions against the principle of least restrictive care.
Physical restraints and chemical sedatives are highly restrictive and carry high risks; visual obscuration, increased observation, and distraction are less restrictive and safer.
Nursing standards of care require attempting and documenting less restrictive alternatives before utilizing physical or chemical restraints.
3
Select the appropriate scope-of-practice and least restrictive interventions.
The correct safety measures include obscuring the IV line, increasing monitoring by moving the room, and providing a safe distractor.
These actions prioritize client safety while adhering to ethical standards and remaining within the practical nurse scope of practice.

Key Concept

Prioritizing least-restrictive safety interventions and recognizing scope of practice limits.
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Topics

Accident, Error, and Injury Prevention

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