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Question

Difficulty: MediumSafe Use of Restraints and Safety Devices

A client is receiving a continuous intravenous infusion of hypertonic saline for the treatment of severe hyponatremia. The client abruptly exhibits profound disorientation, continuously pulling at the intravenous catheter and attempting to climb out of bed. Which intervention should the registered nurse implement first?

  1. A
    Delegate to the unlicensed assistive personnel (UAP) the task of evaluating the client's neurological status every fifteen minutes.
  2. B
    Notify the healthcare provider to request an immediate prescription for bilateral wrist restraints.
  3. Initiate continuous one-to-one observation to maintain safety and provide gentle verbal redirection.Answer
  4. D
    Administer a fast-acting pharmacological sedative to quickly halt the potentially dangerous movements.

Answer

The most appropriate initial intervention is to initiate continuous one-to-one observation to maintain safety and provide gentle verbal redirection.
When a client exhibits acute confusion and behaviors that jeopardize their safety or medical treatment, nursing standards mandate implementing the least restrictive interventions first. Initiating continuous one-to-one observation immediately protects the client from harm, prevents the disruption of the intravenous line, and avoids the legal and physiological risks associated with physical or chemical restraints.

Step-by-Step Solution

1
Analyze the client's immediate safety risk.
The client is actively pulling at a critical intravenous line (hypertonic saline) and attempting to get out of bed, posing an imminent risk for injury and treatment failure.
Identifying the severity of the behavior dictates the urgency and type of intervention required.
2
Evaluate potential interventions based on the principle of least restrictive environment.
Before applying physical or chemical restraints, the nurse must attempt and document alternative, less restrictive safety measures.
Standards of care and legal guidelines mandate that restraints are an intervention of last resort.
3
Select the most appropriate initial action.
Providing a dedicated staff member for continuous observation immediately mitigates the safety risk without unlawfully restricting the client's movement.
Direct observation ensures safety while allowing the nurse to further assess the cause of the sudden disorientation.

Key Concept

Prioritizing least restrictive alternatives before utilizing physical or chemical restraints.
Estimated Time:1m 15s
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Topics

Safe Use of Restraints and Safety Devices

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