A client recovering from a severe traumatic brain injury becomes increasingly restless and repeatedly attempts to remove a central venous catheter. The healthcare provider enters a prescription into the electronic medical record for "bilateral soft wrist restraints as needed (PRN) for severe agitation." Which action should the practical nurse (PN) take first?
- Implement continuous one-to-one observation and notify the provider that PRN restraint prescriptions are legally prohibited.Answer
- BApply the wrist restraints immediately to protect the central line and request the registered nurse to complete the initial assessment.
- CDelegate an assistive personnel to sit with the client and apply the restraints only when the client actively grasps the catheter.
- DAccept the prescription but only apply the restraints during the night shift when the client's confusion is expected to worsen.
Answer
Implement continuous one-to-one observation and notify the provider that PRN restraint prescriptions are legally prohibited.
The correct action recognizes two critical safety principles: PRN (as needed) prescriptions for physical restraints are strictly prohibited by regulatory agencies, and less restrictive alternatives must be exhausted first. By initiating one-to-one observation, the nurse protects the central line safely while addressing the legally invalid prescription with the provider.
Step-by-Step Solution
Key Concept
Legal requirements and alternatives for physical restraints