A client who had abdominal surgery two days ago suddenly becomes disoriented during the evening shift and begins tearing at their wound dressing. Which of the following actions should be taken first to prevent the client from injuring the surgical site?
- Provide the client with a safe, tactile object like a folded washcloth to hold.Answer
- BApply soft wrist restraints immediately to secure the client's hands.
- CPrepare to administer an intravenous push sedative as directed by the charge nurse.
- DDocument the confusion as a typical age-related change expected at nighttime.
Answer
The correct action is to provide the client with a safe, tactile object like a folded washcloth to hold and manipulate.
Providing a diversionary tactile object, such as a folded washcloth, is a highly effective, least-restrictive intervention. It safely redirects the confused client's hands and attention away from the surgical dressing, preventing self-injury without unnecessarily limiting their physical mobility or violating safety protocols.
Step-by-Step Solution
Key Concept
Use of least restrictive alternatives to prevent self-injury