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Question

Difficulty: MediumAccident, Error, and Injury Prevention

While performing midnight rounds, the nurse finds a client who was previously calm now highly agitated. The client is persistently pulling at their intravenous (IV) catheter and attempting to climb out of bed. Which intervention should the nurse implement first to maintain client safety?

  1. Apply a long-sleeved gown to conceal the intravenous site and offer the client a soft washcloth to fold.Answer
  2. B
    Request a prescription for soft extremity restraints to prevent the client from dislodging the intravenous line.
  3. C
    Document the increased nighttime agitation as a typical progression of the client's baseline cognitive status.
  4. D
    Assign assistive personnel to independently monitor the client and assess their neurological status every hour.

Answer

The nurse should implement least restrictive alternatives first, such as concealing the intravenous line with a long-sleeved gown and providing a diversionary activity like folding a washcloth.
The correct action prioritizes client safety while strictly adhering to the principle of using the least restrictive environment. By hiding the IV line with clothing and providing a tactile distraction, the nurse addresses the unsafe behavior safely and effectively without resorting to restraints.

Step-by-Step Solution

1
Assess the immediate risk to the client's safety and medical devices.
The client is identified as being at high risk for falls and accidental removal of their intravenous catheter due to sudden agitation.
Identifying specific safety hazards dictates the urgency and type of interventions needed.
2
Determine the least restrictive intervention that can mitigate the identified risks.
Concealment of the medical device and diversionary strategies are selected as the initial approach.
Nursing standards and client rights require that all less restrictive alternatives be exhausted before considering physical or chemical restraints.
3
Implement the non-pharmacological interventions.
The nurse covers the intravenous site with a long-sleeved gown and provides a safe, familiar object for the client to manipulate.
Out of sight often means out of mind for confused clients, and keeping their hands busy with a safe task prevents picking at medical lines.

Key Concept

Restraint Alternatives and Hazard Mitigation
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Topics

Accident, Error, and Injury Prevention

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