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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A client with a urinary tract infection and acute delirium is admitted to a medical-surgical unit. The client is highly agitated and repeatedly attempts to remove their peripheral intravenous (IV) catheter. Which action should the nurse take FIRST to manage the client's risk for injury?

  1. A
    Contact the healthcare provider immediately to obtain a prescription for bilateral soft wrist restraints.
  2. B
    Delegate the unlicensed assistive personnel (UAP) to evaluate if the client is experiencing pain or bladder distention.
  3. Conceal the IV catheter and attached tubing using a tubular bandage or a long-sleeved gown.Answer
  4. D
    Leave the bedside to rapidly review the client's medication administration record for potential causes of delirium.

Answer

Conceal the IV catheter and attached tubing using a tubular bandage or a long-sleeved gown.
The nurse must prioritize the least restrictive intervention to maintain client safety. Camouflaging medical devices by covering the IV site with a tubular bandage or long-sleeved gown reduces visual stimulation. This prevents the confused client from focusing on and pulling the lines, thereby protecting the IV access without utilizing physical restraints.

Step-by-Step Solution

1
Analyze the client's presentation and immediate safety risks.
The client is experiencing acute delirium and agitation, creating a high risk of self-injury by dislodging an essential IV line.
Understanding the immediate safety threat dictates the priority of nursing interventions.
2
Evaluate potential safety interventions based on the principle of least restrictive measures.
Physical and chemical restraints should be avoided unless absolutely necessary; less restrictive alternatives must be attempted and documented first.
Regulatory standards and evidence-based practice mandate utilizing non-restrictive alternatives before escalating to restraints.
3
Select the most appropriate initial intervention to protect the IV line.
Camouflaging the IV line removes the visual stimulus, safely securing the line without restricting the client's physical movement.
This directly addresses the risk of injury while maintaining the client's freedom and dignity.

Key Concept

Restraint alternatives and the principle of least restrictive interventions in confused clients.
Estimated Time:1m 0s
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Topics

Accident, Error, and Injury Prevention

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