The bed alarm sounds for a client who has severe diabetic peripheral neuropathy and is receiving continuous intravenous (IV) fluids. The nurse enters the room and observes the client standing barefoot next to the bed, attempting to walk to the bathroom unassisted. The IV tubing is stretched taut. Which action should the nurse take first?
- ADirect an available unlicensed assistive personnel (UAP) to ambulate the client while the nurse manages the stretched IV tubing.
- BAssist the client back into bed and request a prescription for soft wrist restraints to prevent further unassisted exits.
- Provide immediate physical support to the client, assess their stability, and assist them to the bathroom.Answer
- DVerbally instruct the client to stand completely still while fetching a wheelchair to transport them safely.
Answer
The nurse should provide immediate physical support to the client, assess their stability, and assist them to the bathroom.
The client is in immediate danger of falling due to neuropathy, being barefoot, and having a taut IV line. The nurse's first priority is to secure the client's physical safety by providing direct support, assessing their current stability, and then safely assisting them with their toileting need.
Step-by-Step Solution
Key Concept
Immediate Fall Prevention and Prioritization