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Question

Difficulty: MediumAccident, Error, and Injury Prevention

An older adult client admitted with a severe urinary tract infection develops acute confusion and repeatedly grasps at their intravenous (IV) catheter. Which action should the nurse take first to protect the client from injury?

  1. Wrap the IV site loosely in a stockinette bandage and give the client a sensory activity apron.Answer
  2. B
    Apply soft wrist restraints and immediately notify the healthcare provider to obtain a prescription.
  3. C
    Direct the unlicensed assistive personnel (UAP) to assess the client's level of orientation every hour.
  4. D
    Document the agitation as an expected age-related cognitive decline and continue standard rounding.

Answer

The nurse should first attempt to camouflage the IV site and provide a safe distraction, as this represents the least restrictive approach to maintaining client safety.
The correct answer employs the principle of using the least restrictive intervention to maintain safety. Camouflaging the medical device (using a stockinette) and redirecting the client's attention (using an activity apron) are effective, non-invasive restraint alternatives that protect the client from self-injury while preserving their autonomy and dignity.

Step-by-Step Solution

1
Analyze the client's behavior and the immediate risk.
The client is experiencing acute confusion and is at high risk for prematurely displacing the IV catheter, leading to injury or interrupted therapy.
Identifying the primary safety threat determines the necessary level of nursing intervention.
2
Evaluate potential interventions based on the principle of least restrictive measures.
Camouflaging the IV line and providing a sensory distraction are identified as the safest, non-invasive initial choices.
Nursing safety standards require exhausting non-restrictive alternatives before applying physical or chemical restraints.
3
Select the option that prioritizes safety without inappropriately delegating nursing assessments or missing acute pathological changes.
Wrapping the IV site and providing an activity apron is chosen over applying physical restraints, delegating assessments to the UAP, or ignoring the acute physiological change.
This action protects the client from self-harm while remaining within the RN's scope of practice and adhering to foundational safety protocols.

Key Concept

Accident, Error, and Injury Prevention: Restraint Alternatives
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Topics

Accident, Error, and Injury Prevention

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