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Question

Difficulty: EasySafe Use of Restraints and Safety Devices

A client receiving intravenous (IV) antibiotics on a general medical unit repeatedly touches and attempts to pull at the IV insertion site. Which action should the nurse implement first to protect the IV line?

  1. Cover the IV insertion site with a breathable, flexible sleeve to conceal it from view.Answer
  2. B
    Apply soft wrist restraints to both of the client's arms to prevent catheter dislodgement.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to assess the IV site every 15 minutes.
  4. D
    Warn the client firmly that they will be tied to the bed if they continue to pull the IV.

Answer

Cover the IV insertion site with a breathable, flexible sleeve to conceal it from view.
Covering the IV site with a sleeve or bandage is a safe, non-restrictive alternative to physical restraints. It relies on the principle of 'out of sight, out of mind,' which is frequently effective in preventing clients from picking at medical devices while fully maintaining their freedom of movement.

Step-by-Step Solution

1
Identify the primary clinical problem.
The client is at risk of dislodging their IV catheter, requiring an intervention to maintain the medical device.
Establishing the problem guides the selection of appropriate safety measures.
2
Recall the legal and ethical principles regarding restraint use.
Nurses must always employ the principle of least restrictive intervention, exhausting and documenting alternative measures before using physical restraints.
Restraints carry significant physical and psychological risks and are legally restricted to being a measure of absolute last resort.
3
Evaluate the available interventions against the least restrictive principle.
Concealing the IV line is a non-restrictive alternative. Restraining the client, delegating assessment to a UAP, and threatening the client are unsafe, illegal, or unethical actions.
Selecting the non-restrictive option ensures client safety while complying with healthcare regulations and standards of care.

Key Concept

Restraint Alternatives and Least Restrictive Environment
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Topics

Safe Use of Restraints and Safety Devices

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