A nurse assumes care for a client experiencing acute delirium who continuously attempts to remove their peripheral intravenous (IV) catheter and indwelling urinary catheter. The client is currently alone in the room. Which intervention should the nurse implement first to protect the client from self-injury?
- Camouflage the catheter tubing under the client's gown and provide an activity apron for their hands.Answer
- BRequest a prescription for soft bilateral wrist restraints from the healthcare provider.
- CAdminister the prescribed as-needed (PRN) dose of an intravenous antipsychotic medication.
- DInstruct the unlicensed assistive personnel (UAP) to sit at the bedside and hold the client's arms down.
Answer
The nurse should first camouflage the catheter tubing under the client's gown and provide an activity apron for their hands.
The correct answer represents the least restrictive alternative. By hiding the tubes from the client's view and providing a tactile distraction (the activity apron), the nurse addresses the behavior caused by delirium without infringing on the client's mobility or rights. This must always be the first step in the hierarchy of safety interventions.
Step-by-Step Solution
Key Concept
Accident, Error, and Injury Prevention: Restraint Alternatives