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Question

Difficulty: MediumAccident, Error, and Injury Prevention

While completing morning vital signs on a medical-surgical unit, the practical nurse (PN) notes that an older adult client being treated for pneumonia has suddenly become acutely confused. The client is forcefully pulling at their peripheral intravenous (IV) catheter. Which initial intervention should the PN implement to maintain the client's safety?

  1. A
    Apply bilateral soft wrist restraints to secure the client's hands away from the catheter.
  2. B
    Administer a prescribed intravenous push (IVP) sedative to rapidly decrease the client's agitation.
  3. Cover the intravenous site and tubing with a flexible tubular bandage.Answer
  4. D
    Inform the client's family that this acute confusion is an anticipated part of the normal aging process.

Answer

The correct action is to cover the intravenous site and tubing with a flexible tubular bandage.
The priority action is to utilize the least restrictive alternative to prevent injury. Concealing the IV site and tubing with clothing or a flexible tubular bandage removes the visual stimulus that often prompts confused clients to pull at medical devices. This protects the client from harm without resorting to physical or chemical restraints.

Step-by-Step Solution

1
Analyze the client's behavior and identify the immediate safety risk.
The client is experiencing acute confusion and is at high risk of dislodging their IV catheter, which could cause bleeding or loss of medication access.
Identifying the primary safety threat determines the urgency and type of intervention needed.
2
Evaluate available interventions based on the principle of least restrictive care.
Concealing the IV site with a bandage or long sleeves is a non-restrictive, immediate action that removes the visual stimulus.
Nursing standards mandate that the least restrictive measures must be attempted before physical or chemical restraints are considered.
3
Assess the appropriateness of other potential actions within the PN scope of practice.
Applying physical restraints requires attempting prior alternatives; administering IV push medications is outside the PN scope; and dismissing the confusion ignores a potential physiological crisis.
Ensuring actions are safe, legal, and within scope prevents medical errors and client harm.

Key Concept

Least Restrictive Alternatives and Scope of Practice in Client Safety
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Topics

Accident, Error, and Injury Prevention

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