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Question

Difficulty: EasySafe Use of Restraints and Safety Devices

An older adult client with mild dementia is hospitalized and receiving continuous intravenous (IV) fluids. The nurse observes the client repeatedly attempting to pull at the IV tubing. Which of the following is the most appropriate initial nursing intervention?

  1. Cover the IV insertion site and tubing with a long-sleeved gown or stockinette.Answer
  2. B
    Apply soft wrist restraints to both upper extremities to prevent IV removal.
  3. C
    Request a prescription for a mild sedative to calm the client's behavior.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to assess why the client is pulling the IV.

Answer

Cover the IV insertion site and tubing with a long-sleeved gown or stockinette.
Covering the IV site with a long-sleeved gown or stockinette is a non-restrictive alternative. Clients with dementia often pick at visible lines because they do not understand their purpose. Camouflaging the equipment removes the visual stimulus, which is an effective first-line strategy to preserve the IV without limiting the client's mobility.

Step-by-Step Solution

1
Identify the immediate safety and clinical problem.
The client is at risk of dislodging their IV line due to confusion, but restricting their freedom of movement poses ethical and safety risks.
Maintaining the IV access is necessary for treatment, but the client's rights must be protected according to restraint guidelines.
2
Recall the standard of care for restraint application.
Restraints (whether physical or chemical) are a last resort.
Nursing standards and hospital policies legally require the implementation and documentation of less restrictive alternatives before using any form of restraint.
3
Select the least restrictive alternative intervention from the available choices.
Camouflaging the IV line is the most appropriate first step.
Covering the site removes the visual trigger for a client with dementia, often resolving the behavior safely without restricting their autonomy.

Key Concept

The nurse must implement and document least restrictive alternatives before utilizing physical or chemical restraints.
Estimated Time:1m 0s
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Topics

Safe Use of Restraints and Safety Devices

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