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Difficulty: Very hardAccident, Error, and Injury Prevention

A practical nurse (PN) responds to a sounding bed alarm in the room of a client receiving treatment for a severe respiratory infection. Upon entering, the PN observes the client, who has a documented history of mild cognitive impairment, attempting to climb over the raised side rails in a dark room. The client is forcefully tugging at their peripheral intravenous (IV) catheter and shouting about being trapped. Which of the following safety interventions should the PN implement? (Select all that apply.)

  1. A
    Apply soft bilateral wrist restraints to secure the peripheral IV and prevent immediate bleeding.
  2. Provide a bedside commode and ensure the room is adequately illuminated with a nightlight.Answer
  3. C
    Instruct the unlicensed assistive personnel (UAP) to evaluate the IV insertion site for signs of infiltration.
  4. Assess the client's oxygen saturation levels and check the suprapubic area for bladder distention.Answer
  5. E
    Record the sudden disorientation as a typical progression of the client's cognitive impairment.
  6. Assign an available staff member to sit with the client and offer a simple, repetitive activity.Answer

Answer

The correct interventions are to provide a bedside commode and adequate lighting, assess oxygen saturation and bladder distention, and assign a staff member to sit with the client while offering a repetitive activity.
The correct actions prioritize safety through least-restrictive measures and clinical investigation. Turning on a nightlight and providing a commode directly address environmental hazards and common toileting urges. Assessing oxygen saturation and bladder fullness investigates critical physiological triggers for sudden delirium, especially in a client with a respiratory infection. Assigning a sitter for observation and distraction is an evidence-based restraint alternative that protects both the client and their IV line.

Step-by-Step Solution

1
Address immediate environmental and physical hazards.
The room is illuminated to prevent tripping, and toileting needs are safely managed with a bedside commode.
Climbing out of bed in the dark poses a severe fall risk, and urgency to void is a primary reason confused clients attempt to get up unassisted.
2
Investigate the underlying cause of the acute behavioral change.
Oxygen levels and bladder distention are assessed by the PN.
Sudden agitation (delirium) is often triggered by physiological stressors such as hypoxia (due to the respiratory infection) or a full bladder, rather than dementia progression.
3
Implement least-restrictive safety measures to protect medical devices.
A staff member sits with the client and provides a distraction activity.
Restraints are a last resort. 1:1 observation and meaningful distraction protect the IV line without violating the client's right to a least-restrictive environment.

Key Concept

Prioritizing least-restrictive restraint alternatives and identifying physiological causes of acute delirium.
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Topics

Accident, Error, and Injury Prevention

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