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Difficulty: EasyAccident, Error, and Injury Prevention

While rounding on a post-surgical unit, a nurse observes a client continuously picking at the edges of their abdominal wound dressing. The client appears disoriented to time and place. Which intervention should the nurse implement first to protect the surgical site while maintaining the least restrictive environment?

  1. Provide the client with a folded washcloth or soft stress ball to manipulate with their hands.Answer
  2. B
    Apply soft cloth wrist restraints and secure the ties to the movable part of the bed frame.
  3. C
    Administer a prescribed as-needed intravenous sedative to decrease the client's restless behavior.
  4. D
    Request a prescription from the healthcare provider to apply bilateral mitten restraints.

Answer

Provide the client with a folded washcloth or soft stress ball to manipulate with their hands.
Providing a safe object for the client to hold is a proven, evidence-based restraint alternative. It successfully redirects the client's tactile seeking behavior and occupies their hands, thereby protecting the surgical dressing without restricting their fundamental freedom of movement.

Step-by-Step Solution

1
Identify the client's risk and current behavior.
The client is disoriented and picking at a surgical dressing, creating a risk for wound contamination and dehiscence.
Recognizing the immediate safety threat is the first step in the clinical decision-making process.
2
Determine the goal of care based on safety principles.
The goal is to protect the surgical site using the least restrictive intervention possible.
Nursing standards and legal guidelines dictate that restraints of any kind must be a last resort.
3
Select the most appropriate initial intervention.
Distracting the client by giving them a harmless object to hold occupies their hands and safely redirects their behavior.
This is an independent nursing action that does not restrict the client's freedom of movement, aligning perfectly with the principle of maintaining the least restrictive environment.

Key Concept

Restraint Alternatives and the Least Restrictive Environment
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Topics

Accident, Error, and Injury Prevention

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