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Question

Difficulty: MediumUse of Restraints and Safety Devices

During the night shift, an elderly client with a severe sacral pressure injury becomes highly restless and confused. The client repeatedly grasps and pulls at the tubing of their negative pressure wound therapy device. Which action should the practical nurse (PN) take first?

  1. Cover the wound therapy equipment with an opaque garment to keep it out of the client's direct view.Answer
  2. B
    Place mitten restraints on the client's hands and notify the provider to obtain an order.
  3. C
    Prepare to administer a prescribed as-needed (PRN) intravenous sedative to calm the client.
  4. D
    Assume the restlessness is an expected finding for an elderly client and dim the room lights.

Answer

Cover the wound therapy equipment with an opaque garment to keep it out of the client's direct view.
The correct action is to cover the medical equipment because it adheres to the principle of using the least restrictive alternative first. Out of sight often means out of mind for a confused client, effectively preventing the removal of the device without restricting the client's freedom of movement.

Step-by-Step Solution

1
Assess the client's behavior and the immediate risk to their safety and medical devices.
The client is restless and attempting to remove necessary medical equipment (wound therapy tubing).
Identifying the specific safety risk determines the appropriate level of intervention required.
2
Determine the least restrictive intervention to prevent the client from removing the device.
Concealing the tubing removes the visual stimulus that prompts the pulling behavior.
Nursing standards mandate that least restrictive alternatives must be implemented and evaluated before resorting to any physical or chemical restraints.

Key Concept

Prioritizing Restraint Alternatives
Estimated Time:1m 0s
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Topics

Use of Restraints and Safety Devices

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