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Zorluk: ZorUse of Restraints and Safety Devices

An older adult client with baseline mild cognitive impairment is hospitalized for a lower respiratory tract infection. During the night shift, the client suddenly becomes highly agitated and repeatedly tugs at their continuous intravenous (IV) infusion tubing. Which interventions should the practical nurse (PN) implement? Select all that apply.

  1. Cover the intravenous insertion site and exposed tubing with a loose stockinette.Cevap
  2. Relocate the client to a room that provides a direct line of sight from the nurses' station.Cevap
  3. C
    Apply bilateral soft wrist restraints immediately to protect the intravenous access.
  4. D
    Document the sudden behavioral change as an expected evening progression of dementia.
  5. E
    Formulate the initial comprehensive nursing care plan regarding restraint criteria.

Cevap

The correct interventions are to cover the intravenous insertion site with a loose stockinette and to relocate the client to a room with a direct line of sight from the nurses' station.
The practical nurse must first attempt less restrictive alternatives before considering restraints. Covering the intravenous site to keep it out of the client's view and moving the client closer to the nurses' station for frequent observation are effective, non-restrictive interventions that fall squarely within the practical nurse's scope of practice.

Adım Adım Çözüm

1
Evaluate the client's sudden agitation and risk for line dislodgement.
The client is identified as being at high risk for self-injury by pulling the intravenous line.
Patient safety is the priority, requiring immediate but appropriate and proportional interventions.
2
Identify least restrictive alternatives to physical restraints.
Methods such as concealing the intravenous site and increasing direct observation are selected.
Restraints must always be a last resort after attempting and documenting less restrictive measures.
3
Determine actions within the practical nurse's scope of practice.
The practical nurse can implement basic safety measures and alternatives, but cannot formulate the initial comprehensive care plan.
Initial comprehensive assessment and care planning are the sole responsibility of the registered nurse.

Anahtar Kavram

Prioritizing least restrictive alternatives and operating within the practical nurse scope of practice.
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Konular

Use of Restraints and Safety Devices

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