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Question

Difficulty: EasyAccident, Error, and Injury Prevention

A practical nurse (PN) is caring for an older adult client who is newly confused and repeatedly attempts to pull out their intravenous (IV) catheter. Which action should the PN take first to prevent injury?

  1. Cover the IV site with a long-sleeved hospital gown or stockinette.Answer
  2. B
    Apply soft wrist restraints to the client's hands.
  3. C
    Assume the confusion is a normal age-related change and gently redirect the client.
  4. D
    Ask an unlicensed assistive personnel (UAP) to monitor the IV site for signs of infiltration.

Answer

Cover the IV site with a long-sleeved hospital gown or stockinette.
Covering the intravenous site with a long-sleeved gown or stockinette hides the site from the client's view, which often naturally reduces the urge to pull on the catheter. This is an effective, non-restrictive alternative that must be attempted before considering any form of physical restraint to ensure the client's safety while preserving their dignity.

Step-by-Step Solution

1
Assess the client's behavior and identify the immediate safety risk.
The client is confused and attempting to dislodge a necessary medical device.
Identifying the specific safety hazard is the first step in determining an appropriate intervention.
2
Select the least restrictive intervention to protect the client and the medical device.
The nurse chooses to cover the site to remove the visual trigger.
Nursing standards and legal guidelines mandate that the least restrictive alternatives must be attempted before any physical restraints are used.

Key Concept

Restraint Alternatives and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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