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Question

Difficulty: HardAccident, Error, and Injury Prevention

A client with severe cognitive impairment is hospitalized for pneumonia and repeatedly attempts to forcefully remove their intravenous (IV) catheter. Place the following nursing interventions in the correct sequential order, starting with the initial least-restrictive assessment and ending with the action of absolute last resort, to ensure client safety.

  1. 1Evaluate the client for reversible physiological triggers such as hypoxia, pain, or a distended bladder.
  2. 2Conceal the intravenous insertion site and tubing by applying a loose, soft stockinette over the client's forearm.
  3. 3Relocate the client to a room directly visible from the nurses' station to facilitate constant observation.
  4. 4Contact the primary healthcare provider to report the ongoing safety risk and obtain a prescription for physical restraints.
  5. 5Secure padded extremity restraints to the movable segment of the bed frame.

Answer

The correct sequence prioritizes client safety by escalating from the least restrictive intervention to the most restrictive: Assess physiological triggers, Conceal the IV site, Relocate the client for observation, Contact the provider for a prescription, and finally Secure the restraints.
The correct sequence follows the evidence-based nursing standard for restraint application: it begins with independent nursing assessments to rule out physiological causes, progresses to least-restrictive bedside interventions (camouflaging), escalates to increased supervision (room relocation), and only then seeks a provider prescription to implement the most restrictive measure (physical restraints).

Step-by-Step Solution

1
Evaluate the client for reversible physiological triggers such as hypoxia, pain, or a distended bladder.
Underlying causes of agitation are identified and addressed.
Agitation is often a symptom of an unmet physical need; resolving the root cause is the least restrictive and most effective primary intervention.
2
Conceal the intravenous insertion site and tubing by applying a loose, soft stockinette over the client's forearm.
The medical device is obscured from the client's line of sight.
If agitation persists, camouflaging the site is a low-risk, non-restrictive bedside modification that often prevents the client from fixating on the IV.
3
Relocate the client to a room directly visible from the nurses' station to facilitate constant observation.
The client receives enhanced environmental supervision.
When bedside modifications fail, moving the client to a highly visible area increases safety without restricting their physical freedom.
4
Contact the primary healthcare provider to report the ongoing safety risk and obtain a prescription for physical restraints.
Legal authorization for restraints is obtained.
Mechanical restraints cannot be applied without a documented medical order, which should only be requested after all less restrictive alternatives have proven ineffective.
5
Secure padded extremity restraints to the movable segment of the bed frame.
The client is physically prevented from removing the life-sustaining IV.
Applying physical restraints is strictly a measure of absolute last resort to prevent imminent harm, and they must be secured safely to avoid injury during bed adjustments.

Key Concept

Hierarchy of Restraint Alternatives and Client Safety
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Topics

Accident, Error, and Injury Prevention

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