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Difficulty: MediumAccident, Error, and Injury Prevention

An 82-year-old client is admitted to a subacute care unit for nutritional support via a newly placed percutaneous endoscopic gastrostomy (PEG) tube. During the evening shift, the client becomes abruptly agitated and repeatedly attempts to pull at the tube. Which action should the practical nurse (PN) take first to prevent injury to the client?

  1. Cover the gastrostomy tube with a loose abdominal binder to conceal it from the client's view.Answer
  2. B
    Secure the client's hands with soft wrist restraints to prevent immediate dislodgement of the tube.
  3. C
    Assign the unlicensed assistive personnel (UAP) to perform a comprehensive neurological assessment.
  4. D
    Document the client's sudden agitation as an expected age-related cognitive change.

Answer

The practical nurse should prioritize least restrictive measures, such as covering the gastrostomy tube with an abdominal binder, to protect the device while maintaining client safety.
The correct answer emphasizes client safety through the use of least restrictive alternatives. Concealing a medical device using a loose binder or clothing often reduces a confused client's visual fixation on the device. This simple intervention can prevent accidental removal and injury without the ethical and physical risks associated with physical restraints.

Step-by-Step Solution

1
Analyze the clinical situation and the client's immediate risk.
The client is experiencing sudden agitation and is at high risk for injuring themselves by removing a necessary medical device (the PEG tube).
Identifying the primary safety hazard is the first step in determining the appropriate nursing intervention.
2
Identify the safest and most appropriate initial intervention.
Implementing a least restrictive alternative, such as concealing the device from sight, is the standard of care before considering any physical restraints.
Restraints can exacerbate agitation and pose additional safety risks; therefore, non-restrictive measures must always be attempted first.
3
Evaluate alternative actions to ensure they are within scope and clinically sound.
Assessing the client's change in condition cannot be delegated, and sudden confusion must be investigated rather than dismissed as normal aging.
Ensuring actions fall within the PN scope of practice and reflect accurate clinical judgment prevents further client harm.

Key Concept

Implementing least restrictive alternatives to prevent client injury
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Topics

Accident, Error, and Injury Prevention

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