Following a change-of-shift report, a practical nurse (PN) assumes care for a client who is recovering from a surgical hip fracture repair. The off-going nurse states that a provider prescription for soft wrist restraints was just obtained because the client became restless and attempted to remove their surgical dressing. Which action should the PN take first?
- Assess the client to identify potential causes for the restlessness and implement less restrictive safety measures.Cevap
- BSecure the prescribed soft wrist restraints to the movable portion of the bed frame immediately.
- CDelegate the responsibility of hourly neurovascular assessments to an unlicensed assistive personnel (UAP).
- DDocument the restlessness as a standard manifestation of chronic dementia and proceed with routine care.
Cevap
The priority action is to assess the client to identify potential causes for the restlessness and implement less restrictive safety measures.
The correct action prioritizes the nursing process (assessment first) and adheres to the safety principle of utilizing the least restrictive environment. Sudden restlessness in a postoperative client may indicate an acute complication like hypoxia or uncontrolled pain, which must be addressed before resorting to restraints.
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Anahtar Kavram
Restraints should only be used as a last resort after attempting less restrictive alternatives and identifying potential underlying causes of the behavior.