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Question

Difficulty: EasyAccident, Error, and Injury Prevention

A client who is experiencing confusion keeps attempting to remove their peripheral intravenous (IV) catheter. Which of the following is the most appropriate initial nursing action to protect the IV site?

  1. Cover the intravenous site with a protective stockinette or long-sleeved gown.Answer
  2. B
    Apply soft physical wrist restraints to both of the client's upper extremities.
  3. C
    Delegate the assessment of the client's confusion to the unlicensed assistive personnel (UAP).
  4. D
    Request a prescription for a sedative to calm the client and prevent device removal.

Answer

Covering the intravenous site with a protective stockinette or long-sleeved gown is the most appropriate initial action.
The least restrictive intervention must always be attempted first before considering physical or chemical restraints. Covering the IV site with a stockinette conceals the catheter from the confused client's view, which often prevents them from picking at it while maintaining their freedom of movement.

Step-by-Step Solution

1
Identify the primary safety issue.
The confused client is at risk of dislodging their IV catheter, which could cause harm or delay treatment.
Accurate identification of the risk is required to select the proper intervention.
2
Apply the principle of least restrictive interventions.
The nurse must select a strategy that protects the medical device without unnecessarily restricting the client's freedom or using medication.
Nursing standards and regulations mandate that physical or chemical restraints be used only as a last resort.
3
Evaluate the available options against this principle.
Concealing the IV site is a non-restrictive alternative that often prevents confused clients from picking at medical devices.
Removing the visual stimulus is a safe and effective initial measure.

Key Concept

Restraint alternatives and the principle of least restrictive interventions.
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Topics

Accident, Error, and Injury Prevention

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