A practical nurse (PN) is caring for an older adult client who is experiencing acute confusion and repeatedly attempting to pull out their intravenous (IV) line. The client's spouse is visibly distressed and demands that the PN immediately apply wrist restraints to prevent the client from disrupting the treatment. Which action should the PN take first to advocate for the client's right to a safe and least restrictive environment?
- Conceal the IV insertion site using a tubular bandage and provide the client with a safe item to hold for distraction.Answer
- BInform the spouse that a healthcare provider's prescription is legally required before the staff can apply physical restraints.
- CApply soft wrist restraints temporarily to protect the IV access and immediately contact the healthcare provider for a prescription.
- DAsk the client, 'Why do you keep pulling at your IV line when you need this medication to recover?'
Answer
The correct action is to conceal the IV insertion site and provide a safe item for the client to hold as a distraction.
The correct answer demonstrates advocacy by protecting the client's right to a least restrictive environment. By hiding the IV site and giving the client something else to occupy their hands, the practical nurse effectively addresses the safety concern (maintaining IV access) without resorting to physical restraints.
Step-by-Step Solution
Key Concept
Client Rights: Least Restrictive Environment and Restraint Alternatives