A nurse is managing the care of an ambulatory older adult client with moderate Alzheimer's disease who is hospitalized for dehydration. The client is receiving continuous intravenous (IV) fluids, appears agitated, frequently paces the hallway, and repeatedly pulls at the IV tubing. The client's family has just left for the evening. Which intervention should the nurse implement first to prevent injury and maintain the IV line?
- Cover the intravenous insertion site with a tubular elastic dressing and give the client a familiar object to hold.Cevap
- BRaise all four side rails on the client's bed and activate a bed exit alarm to keep the client safely in the room.
- CDelegate to unlicensed assistive personnel (UAP) to walk with the client and evaluate their level of orientation.
- DAdminister a prescribed as-needed dose of an antianxiety medication to decrease pacing and protect the intravenous line.
Cevap
Cover the intravenous insertion site with a tubular elastic dressing and give the client a familiar object to hold.
The correct answer employs the principle of using the least restrictive intervention first. Clients with dementia who pick at medical devices often do so because the device is visible and acts as a bother or foreign object. Concealing the intravenous site with a tubular elastic dressing removes the visual trigger. Providing a familiar object or activity apron serves as a safe diversionary tactic, occupying the client's hands and reducing the likelihood of them dislodging the line.
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Restraint Alternatives and Injury Prevention