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Question

Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client is admitted to the medical-surgical unit with pneumonia. During the night shift, the client becomes acutely confused and repeatedly attempts to pull out their peripheral intravenous (IV) catheter. Which initial nursing action is the most appropriate to prevent injury and maintain the integrity of the IV line?

  1. Conceal the intravenous insertion site using a tubular elastic bandage or long sleeves.Answer
  2. B
    Obtain a prescription to apply bilateral soft wrist restraints.
  3. C
    Document the client's confusion as an expected age-related change.
  4. D
    Delegate the unlicensed assistive personnel (UAP) to evaluate the client's ongoing need for safety devices.

Answer

The most appropriate initial action is to conceal the IV site using a tubular elastic bandage or long sleeves.
Hiding the IV site from the client's view using a stockinette or long sleeves is a standard, non-restrictive alternative. For clients with acute confusion or dementia, simply removing the medical device from their line of sight often prevents them from picking at or removing it, thereby maintaining safety without resorting to physical restraints.

Step-by-Step Solution

1
Assess the client's behavior and the risk to their safety and ongoing treatment.
The client is at high risk for self-injury and disruption of medical therapy by pulling out the IV catheter.
Identifying the specific safety risk guides the selection of targeted interventions.
2
Recall the principles of restraint use and injury prevention.
The standard of care mandates that the least restrictive measures must be utilized before considering physical or chemical restraints.
Restraints can cause further injury, agitation, and loss of dignity, and are strictly regulated.
3
Select the least restrictive intervention from the available options.
Concealing the IV site is a recognized, non-restrictive alternative that addresses the immediate problem.
Out of sight often means out of mind for a confused client, effectively protecting the line without limiting mobility.

Key Concept

Accident, Error, and Injury Prevention: Least Restrictive Alternatives
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Topics

Accident, Error, and Injury Prevention

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