Examkin

Question

Difficulty: Very hardUse of Restraints and Safety Devices

An 82-year-old client is admitted to the medical-surgical unit for treatment of bacterial pneumonia and is receiving continuous intravenous (IV) antibiotics. During the night shift, the client suddenly begins picking at the air, speaking incoherently, and forcefully grasping the IV tubing. The client has no history of cognitive impairment. A review of the client's admission orders reveals a prescription written 12 hours ago: "Apply soft bilateral wrist restraints PRN (as needed) for agitation or line interference." Which sequence of actions demonstrates the most appropriate clinical judgment by the practical nurse (PN)?

  1. A
    Apply the soft wrist restraints to prevent dislodgment of the IV line, as the prescription was written within the acceptable 24-hour validity window.
  2. B
    Accept the charge nurse's delegation to apply the restraints and perform the initial behavioral assessment, as the client is actively interfering with medical treatment.
  3. C
    Conclude that the client is experiencing expected nocturnal delirium associated with advanced age, apply the restraints using a quick-release knot, and monitor circulation every 2 hours.
  4. Withhold the restraints because PRN prescriptions are legally invalid, assess the client's oxygenation status, and notify the registered nurse (RN) of the acute status change.Answer

Answer

The correct action is to withhold the restraints due to the invalid PRN order, assess the client's oxygenation, and immediately notify the RN.
The correct answer demonstrates expert-level clinical synthesis. First, it acknowledges the absolute legal boundary that PRN (as needed) prescriptions for physical restraints are prohibited under all circumstances; a new, specific order is required for application. Second, it recognizes that sudden confusion and restlessness in a client with pneumonia is a hallmark sign of hypoxia, necessitating immediate physiological assessment (such as checking oxygen saturation) rather than assuming primary behavioral agitation. Finally, reporting this acute clinical change to the RN aligns perfectly with the PN's collaborative scope of practice.

Step-by-Step Solution

1
Evaluate the legality and validity of the restraint prescription.
Identify that the prescription is written as "PRN" (as needed), which is strictly prohibited by federal and facility regulations for physical restraints.
Restraints require a specific, time-limited order based on a current, face-to-face provider assessment. PRN orders are never legally valid for restraints.
2
Analyze the client's clinical presentation.
Recognize that an 82-year-old with pneumonia who suddenly becomes confused and picks at the air is likely experiencing acute hypoxia or sepsis.
Sudden behavioral changes in the elderly should never be assumed to be primary agitation or expected delirium without first ruling out life-threatening physiological causes.
3
Determine the appropriate scope of practice response.
Perform a focused physiological assessment (checking oxygen saturation) and immediately escalate the findings to the supervising RN.
The PN must gather foundational data regarding the acute change and collaborate with the RN, who is responsible for the initial complex assessment and coordination of a new care plan.

Key Concept

Legal requirements for restraint prescriptions and prioritization of physiological needs in acutely confused clients.
Rate this question

Topics

Use of Restraints and Safety Devices

More questions from this topic