A nurse is planning care for a client who is severely agitated, disoriented, and repeatedly attempting to remove a newly placed central venous catheter (CVC). The client has disseminated herpes zoster and is in a negative-pressure isolation room. Which of the following is the most appropriate initial action by the nurse to prevent patient injury and ensure environmental safety?
- Implement continuous one-to-one observation by a trained staff member equipped with appropriate airborne and contact personal protective equipment.Answer
- BApply bilateral soft wrist restraints as the primary intervention to prevent central line dislodgment, followed by notifying the healthcare provider.
- CAssign the unlicensed assistive personnel (UAP) to evaluate the client's level of agitation and the integrity of the CVC insertion site every 15 minutes.
- DLeave the door to the negative-pressure room slightly ajar so staff at the nurses' station can continuously visually monitor the client's actions.
Answer
Implement continuous one-to-one observation by a trained staff member equipped with appropriate airborne and contact personal protective equipment.
Implementing continuous one-to-one observation is the most appropriate initial action. It provides the least restrictive alternative to physical restraints while ensuring immediate intervention if the client attempts to remove the central line. Furthermore, ensuring the observer wears the correct personal protective equipment maintains adherence to the required airborne and contact precautions for disseminated herpes zoster.
Step-by-Step Solution
Key Concept
Accident, Error, and Injury Prevention (Restraint Alternatives, Delegation, and Isolation Integrity)