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Difficulty: EasySafe Use of Restraints and Safety Devices

During bedside rounds, a nurse observes that a postoperative client is confused and continuously grasping at their indwelling urinary catheter tubing. To prevent premature removal of the device, which action should the nurse take first?

  1. Offer the client a rolled-up towel or sensory item to hold.Answer
  2. B
    Initiate soft cloth restraints on the client's wrists.
  3. C
    Assign the unlicensed assistive personnel (UAP) to assess the client's mental status frequently.
  4. D
    Administer a prescribed as-needed sedative to decrease the client's agitation.

Answer

The most appropriate initial action is to offer the client a rolled-up towel or sensory item to hold, acting as a safe distraction.
The standard of care for client safety requires nurses to implement the least restrictive measures first. Providing a sensory item or a safe object to hold occupies the client's hands and can effectively deter them from pulling on essential medical devices without requiring physical or chemical restraints.

Step-by-Step Solution

1
Identify the primary safety concern based on the client's behavior.
The confused client is at immediate risk of dislodging their indwelling urinary catheter.
Recognizing the specific risk allows the nurse to select a targeted safety intervention.
2
Determine the least restrictive intervention to address the behavior.
Providing a distraction or sensory item for the client's hands is selected as the first approach.
Nursing standards mandate that least restrictive alternatives must be attempted before applying any physical or chemical restraints.

Key Concept

The nurse must always implement and document least restrictive alternatives (such as distraction, reorientation, or concealment of tubes) before resorting to physical or chemical restraints.
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Topics

Safe Use of Restraints and Safety Devices

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