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Question

Difficulty: MediumAccident, Error, and Injury Prevention

A nurse is caring for an older adult client who is experiencing acute confusion and repeatedly attempting to pull out their peripheral intravenous (IV) catheter. Which action should the nurse take to maintain patient safety and prevent injury?

  1. Cover the IV insertion site with a continuous tubular bandage to conceal it from the client's viewAnswer
  2. B
    Apply bilateral soft wrist restraints immediately to ensure the IV line remains securely intact
  3. C
    Assign an unlicensed assistive personnel (UAP) to evaluate the underlying cause of the client's sudden confusion
  4. D
    Document the client's altered mental status as an expected physiological change associated with advanced age

Answer

The correct action is to cover the IV insertion site with a continuous tubular bandage to conceal it from the client's view.
Nursing standards of care require the implementation of the least restrictive measures possible before applying any form of physical restraint. Concealing medical devices, such as an IV catheter, using a stockinette, long sleeves, or a continuous tubular bandage is an effective, non-restrictive alternative. It often decreases a confused client's visual fixation on the device, thereby preventing self-injury without limiting the client's mobility or violating their autonomy.

Step-by-Step Solution

1
Identify the primary safety risk presented in the scenario.
The client is at risk for self-injury and loss of vascular access due to acute confusion and pulling behavior.
Recognizing the specific hazard is the first step in formulating a targeted safety plan.
2
Evaluate potential interventions based on restrictiveness and scope of practice.
Concealing the IV site is a non-restrictive alternative. Restraints are highly restrictive. Assessing confusion requires nursing judgment.
Nursing standards mandate using the least restrictive intervention first and strictly prohibit delegating assessments to unlicensed personnel.
3
Select the most appropriate, least restrictive action.
Covering the IV site is chosen as the initial safety intervention.
This effectively mitigates the risk of self-injury by removing the visual trigger, without inappropriately restricting the client's movement or making unsafe clinical assumptions.

Key Concept

Restraint Alternatives and Injury Prevention
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Topics

Accident, Error, and Injury Prevention

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