A family member reports that an 82-year-old client, admitted for dehydration, is suddenly talking to the wall and repeatedly pulling at their intravenous (IV) catheter. Which action should the practical nurse implement to ensure safety?
- Cover the IV insertion site with a loose stockinette to conceal it from the client's view.Answer
- BApply bilateral soft wrist restraints to prevent the client from dislodging the line.
- CReassure the family that this sudden confusion is a normal part of the aging process.
- DAssign the unlicensed assistive personnel to perform a baseline neurological assessment.
Answer
Cover the IV insertion site with a loose stockinette to conceal it from the client's view.
When a client attempts to remove medical devices due to confusion, the nurse must first implement the least restrictive interventions. Camouflaging the intravenous line with clothing or a loose stockinette removes the visual trigger. This simple action often prevents the client from pulling on the line, thereby ensuring safety and preventing injury without the use of physical restraints.
Step-by-Step Solution
Key Concept
Implementing least restrictive alternatives for injury prevention