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Question

Difficulty: EasyUse of Restraints and Safety Devices

A client with acute confusion is repeatedly attempting to pull out their peripheral intravenous (IV) catheter. Which action should the practical nurse (PN) take first to ensure the client's safety?

  1. Cover the IV insertion site with a long sleeve or flexible tubular bandageAnswer
  2. B
    Apply soft wrist restraints to the client's upper extremities
  3. C
    Explain to the family that sudden confusion is a normal part of the aging process
  4. D
    Request a prescription for a chemical restraint to immediately calm the client

Answer

Cover the IV insertion site with a long sleeve or flexible tubular bandage.
The correct action is to cover the IV site, which serves as a least restrictive alternative. By hiding the IV catheter from the client's view, the visual trigger to pull at it is removed, potentially eliminating the need for any type of physical or chemical restraint.

Step-by-Step Solution

1
Identify the primary safety risk.
The client is at risk of dislodging their IV catheter due to acute confusion.
Recognizing the specific risk dictates the appropriate, targeted nursing intervention.
2
Determine the least restrictive intervention.
Concealing the IV line removes the visual stimulus that prompts the client to pull on it.
Nursing standards mandate that restraints must only be used after less restrictive measures have been attempted and proven ineffective.

Key Concept

Least Restrictive Environment and Restraint Alternatives
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Topics

Use of Restraints and Safety Devices

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