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Difficulty: MediumAccident, Error, and Injury Prevention

A practical nurse (PN) enters a client's room and observes a geriatric client becoming increasingly agitated and grasping at their indwelling urinary catheter. The client's spouse states that this confused behavior started suddenly this morning. Which action should the PN take first to ensure client safety?

  1. Check the client's oxygen saturation, obtain vital signs, and inspect the catheter for proper drainage.Answer
  2. B
    Apply bilateral soft wrist restraints to immediately stop the client from dislodging the catheter.
  3. C
    Reassure the spouse that sudden confusion is an expected age-related change and continue routine care.
  4. D
    Accept a verbal prescription from the healthcare provider to administer an intravenous (IV) push sedative.

Answer

The priority action is to check the client's oxygen saturation, obtain vital signs, and inspect the catheter for proper drainage.
Checking vital signs, oxygen levels, and the catheter tubing addresses the most likely physiological causes of sudden delirium (such as hypoxia or a distended bladder from a blocked tube). By identifying and correcting the root cause, the nurse safely prevents the client from dislodging the catheter while remaining within the practical nursing scope of data collection.

Step-by-Step Solution

1
Analyze the client's presentation of sudden-onset confusion and agitation.
Recognize these symptoms as acute delirium rather than a baseline cognitive deficit.
Sudden changes in mental status in geriatric clients are typically triggered by physiological factors like hypoxia, urinary retention, or infection.
2
Determine the priority nursing action to maintain safety.
Prioritize identifying the physiological cause of the agitation before implementing restrictive measures.
Resolving the underlying cause (e.g., unkinking a blocked catheter or applying oxygen) naturally de-escalates the behavior and eliminates the risk of self-injury.
3
Select the intervention that falls within the practical nurse (PN) scope of practice.
Choose data collection methods (vital signs, oxygen saturation, physical inspection of equipment) over IV push medications.
Data collection is firmly within the PN scope, whereas administering IV push sedatives or bypassing restraint alternatives violates safe practice standards.

Key Concept

In geriatric clients, sudden agitation or confusion is typically a symptom of an acute physiological problem (delirium) rather than normal aging. The priority for injury prevention is safely investigating the underlying cause using least restrictive measures.
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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