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Question

Difficulty: HardAccident, Error, and Injury Prevention

A practical nurse (PN) is assigned to care for an older adult client who is experiencing acute confusion on the first postoperative day. The client is highly restless and repeatedly attempts to remove their surgical dressing. Which action should the PN take FIRST to prevent client injury and maintain a safe environment?

  1. Conceal the surgical site using a protective stockinette and provide a diversionary object for the client to hold.Answer
  2. B
    Apply prescribed soft wrist restraints bilaterally to immediately prevent the client from dislodging the dressing.
  3. C
    Assign the unlicensed assistive personnel (UAP) to sit with the client and evaluate the surgical wound for bleeding.
  4. D
    Place the client in a high-Fowler's position with the knees sharply flexed to limit their physical ability to reach the surgical site.

Answer

The correct priority action is to conceal the surgical site using a protective stockinette and provide a diversionary object for the client to hold.
Concealing the surgical site (such as with a stockinette or long sleeves) and providing a diversionary object are highly effective, least-restrictive restraint alternatives. In confused clients, removing the visual stimulus of the dressing often stops the picking behavior. The diversion keeps their hands safely occupied, ensuring client safety without violating their rights or inappropriately restricting movement.

Step-by-Step Solution

1
Analyze the client's presentation and immediate risk.
The client is postoperative, confused, and picking at a surgical dressing, creating an immediate risk for infection, bleeding, and impaired wound healing.
Identifying the specific safety hazard dictates the urgency and type of intervention required.
2
Evaluate the proposed interventions against the principle of least restrictive measures.
Applying restraints limits freedom and can increase agitation. Repositioning with flexed knees creates a physiological hazard. Delegating wound evaluation violates scope of practice.
Nursing standards require prioritizing safety while maintaining client rights and adhering to legal scopes of practice.
3
Select the safest, least restrictive, and within-scope intervention.
Concealing the dressing removes the visual trigger, and providing a diversionary object safely occupies the client's hands.
This approach effectively mitigates the risk without compromising client rights or introducing new physiological dangers.

Key Concept

Restraint Alternatives and Injury Prevention
Estimated Time:1m 15s
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Topics

Accident, Error, and Injury Prevention

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