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Difficulty: MediumUse of Restraints and Safety Devices

While conducting nightly rounds on a cardiac step-down unit, the practical nurse (PN) observes that an older adult client who was previously oriented is now highly agitated and pulling aggressively at their peripheral intravenous (IV) line. Which intervention should the PN implement first to protect the IV access and ensure client safety?

  1. Conceal the IV site with a tubular stockinette and provide the client with a safe, tactile object to hold.Answer
  2. B
    Contact the healthcare provider to obtain a prescription for soft limb restraints to prevent line removal.
  3. C
    Provide a detailed explanation to the client regarding why the IV access is critical for their recovery.
  4. D
    Document the agitation as a typical manifestation of age-related sundowning and continue routine observations.

Answer

The intervention that conceals the IV site and provides a tactile distraction is the correct initial action.
The correct action demonstrates the principle of utilizing the least restrictive alternative. In situations where a client is agitated and risks pulling medical lines, the nurse must first attempt non-restrictive interventions. Camouflaging the IV line removes the visual stimulus that prompts the pulling behavior, and providing a washcloth or similar safe object redirects the client's restless hands safely without restricting their freedom.

Step-by-Step Solution

1
Analyze the client's behavior and the immediate risk to their safety and treatment.
The client is experiencing acute agitation and is at high risk of dislodging a necessary medical device.
Recognizing the immediate threat helps prioritize nursing actions while maintaining safety.
2
Evaluate the available interventions against the standard of care for restraint use.
Physical restraints are a last resort; less restrictive alternatives must be attempted first.
Ethical and regulatory standards mandate maintaining the client's freedom of movement whenever possible.
3
Select the intervention that protects the IV line while remaining the least restrictive.
Using a stockinette to hide the IV and providing a distraction object safely manages the behavior.
This approach targets the root of the behavior (restlessness and visual triggers) without imposing physical limitations.

Key Concept

Implementing Least Restrictive Alternatives
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Topics

Use of Restraints and Safety Devices

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