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Difficulty: MediumUse of Restraints and Safety Devices

A practical nurse (PN) is caring for a 74-year-old client who is two days postoperative following an open reduction and internal fixation of a fractured hip. The client is becoming increasingly restless and repeatedly attempts to climb over the bed rails to use the restroom, despite having an indwelling urinary catheter in place. The client's family expresses concern about a potential fall and asks the PN to apply restraints. Which of the following is the most appropriate initial response or action by the PN?

  1. Implement alternative safety measures, such as moving the client closer to the nurses' station and activating a bed alarm.Answer
  2. B
    Raise all four side rails on the client's bed to create a safe physical barrier that does not require a formal provider prescription.
  3. C
    Reassure the family that this sudden confusion is a normal, expected part of the aging process after surgery and will soon pass.
  4. D
    Ask the family why they feel physical restraints are the best option for a client who is simply trying to use the restroom.

Answer

Implement alternative safety measures, such as moving the client closer to the nurses' station and activating a bed alarm.
The standard of nursing practice mandates that physical restraints must be a measure of last resort. The nurse must always attempt, evaluate, and document less restrictive alternatives first. Moving the client closer to the nurses' station for closer observation and utilizing bed alarms are effective, least-restrictive safety interventions that protect the client from falls while maintaining their freedom of movement.

Step-by-Step Solution

1
Analyze the client's behavior and the family's request.
The client is restless and attempting to get out of bed unsafely. The family is requesting restraints to prevent a fall.
Identifying the core problem helps determine the safest and most legally appropriate nursing intervention.
2
Evaluate the clinical guidelines regarding physical restraints.
Restraints are always a last resort. Nurses must first attempt and document less restrictive alternatives before obtaining an order for restraints.
Using the least restrictive environment is a fundamental client right and a strict regulatory standard.
3
Select the nursing action that prioritizes safety while avoiding premature restraint use.
Moving the client closer to the nurses' station and using bed alarms provides enhanced monitoring and safety without physically restricting the client.
This intervention directly addresses the fall risk utilizing evidence-based restraint alternatives.

Key Concept

Prioritizing Restraint Alternatives
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Topics

Use of Restraints and Safety Devices

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