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Soru

Zorluk: OrtaUse of Restraints and Safety Devices

A 79-year-old client is receiving a continuous intravenous (IV) antibiotic infusion for the treatment of pneumonia. The client becomes increasingly restless and repeatedly attempts to pull at the IV tubing. Which action should the practical nurse (PN) implement first to protect the IV site?

  1. A
    Apply prescribed soft wrist restraints immediately to prevent dislodgment of the catheter.
  2. B
    Inform the family that this sudden onset of restlessness is a normal age-related response to hospitalization.
  3. Camouflage the intravenous tubing using a loose stockinette to redirect the client's attention.Cevap
  4. D
    Perform a comprehensive clinical assessment to independently identify the underlying cause of the restlessness.

Cevap

Camouflage the intravenous tubing using a loose stockinette to redirect the client's attention.
The correct answer emphasizes that the application of physical restraints must always be a last resort. The practical nurse (PN) should first implement least-restrictive alternatives, such as camouflaging the intravenous tubing, providing diversionary activities, or promoting a calm environment, to ensure client safety without limiting mobility.

Adım Adım Çözüm

1
Analyze the clinical scenario.
The client is an older adult showing sudden restlessness and pulling at a medical device (IV line).
To determine the immediate risk and appropriate nursing intervention.
2
Evaluate the nursing scope of practice.
The PN must take action to ensure safety but cannot perform initial comprehensive diagnostic assessments.
To ensure the chosen intervention is within the legal boundaries of a practical nurse.
3
Prioritize interventions based on restraint guidelines.
The least restrictive measure must be implemented before considering any physical restraints.
To uphold client rights, maintain dignity, and comply with safety regulations regarding restraint use.

Anahtar Kavram

Least Restrictive Alternatives
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Konular

Use of Restraints and Safety Devices

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