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Question

Difficulty: EasyUse of Restraints and Safety Devices

A family member requests that the practical nurse apply wrist restraints to a hospitalized client who is confused and continuously tugging at their intravenous (IV) catheter. Which action should the practical nurse implement first?

  1. Cover the intravenous site with a tubular bandage to conceal it from the client's view.Answer
  2. B
    Contact the healthcare provider to obtain a prescription for restraints to be used as needed.
  3. C
    Inform the family that the sudden onset of confusion is a typical part of the aging process.
  4. D
    Delegate the responsibility of assessing the client's behavioral status to the assistive personnel.

Answer

Cover the intravenous site with a tubular bandage to conceal it from the client's view.
Before applying any physical restraints, the nurse must attempt less restrictive alternatives. Concealing the intravenous site with a bandage, clothing, or stockinette is a safe, non-restrictive intervention that effectively prevents many confused clients from picking at or dislodging their medical lines.

Step-by-Step Solution

1
Identify the clinical safety issue.
The client is experiencing confusion and is at risk of dislodging an essential intravenous catheter.
Recognizing the risk is the first step in formulating a safe clinical response.
2
Determine the priority nursing intervention based on standards of care.
The nurse selects concealing the intravenous site over applying physical restraints.
Clinical standards require that least restrictive alternatives must be attempted and documented before physical restraints are considered.

Key Concept

Least Restrictive Alternatives
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Topics

Use of Restraints and Safety Devices

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