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Difficulty: MediumAccident, Error, and Injury Prevention

A client is recovering on the surgical unit following a hip arthroplasty. The family reports that the client, who has no history of cognitive impairment, is abruptly pulling at their surgical dressing and attempting to get out of bed unassisted. Which action is the priority for the practical nurse (PN) to implement to prevent injury?

  1. Assess the client for physiological triggers such as hypoxia, acute pain, or a full bladder.Answer
  2. B
    Secure bilateral soft wrist restraints to protect the surgical incision from being compromised.
  3. C
    Educate the family that sudden disorientation is an expected age-related change during hospitalization.
  4. D
    Administer an intravenous push (IVP) dose of a prescribed sedative to rapidly calm the client.

Answer

Assess the client for physiological triggers such as hypoxia, acute pain, or a full bladder.
When a previously oriented client becomes acutely restless or confused, it often indicates an underlying physiological problem such as decreased oxygenation, unrelieved pain, or urinary retention. Identifying and treating the root cause is the priority safety intervention before considering restrictive measures.

Step-by-Step Solution

1
Analyze the client's new-onset behavior.
The client is demonstrating acute restlessness and agitation, posing an immediate risk to their surgical site and physical safety.
Recognizing a sudden change in baseline mental status is critical for patient safety.
2
Determine the safest initial nursing intervention.
Identify that the most effective way to prevent injury is to resolve the underlying cause of the agitation.
Restrictive measures should never be the first step. Acute confusion is often a symptom of hypoxia, pain, or urinary retention, which can be quickly assessed and treated.

Key Concept

Restraint Alternatives and Root Cause Assessment
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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