A practical nurse (PN) is caring for a client with altered mental status who is repeatedly attempting to pull out their continuous intravenous (IV) catheter. Place the following nursing actions in the correct sequence, beginning with the initial action and progressing from the least restrictive to the most restrictive intervention. (All options must be used).
- 1Assess the client's oxygen saturation, pain level, and bladder distention.
- 2Camouflage the intravenous tubing by wrapping it loosely in a cohesive bandage and placing it under the client's sleeve.
- 3Provide a safe diversionary activity, such as offering an activity apron or washcloths to fold.
- 4Collaborate with the nursing supervisor to arrange for a continuous one-to-one bedside sitter.
- 5Notify the healthcare provider to request a prescription for bilateral soft wrist restraints.
Answer
The correct sequence is to first assess for physiological causes, then camouflage the tubing, provide a diversionary activity, arrange for a bedside sitter, and finally request a prescription for restraints as a last resort.
The nursing process requires assessing the client first to identify treatable causes of agitation. Once physiological needs are ruled out, the nurse must exhaust alternatives to restraints, escalating from passive environmental changes (camouflaging tubes) to active behavioral interventions (diversion), then to human supervision (a sitter). Only when all these less restrictive measures fail can the nurse request physical restraints.
Step-by-Step Solution
Key Concept
The hierarchy of restraint alternatives dictates that nurses must first assess for physiological causes of agitation, then systematically implement interventions progressing from least restrictive (environmental and diversionary) to most restrictive (physical restraints).