An overnight registered nurse is planning care for a client who has Clostridioides difficile (C. diff) infection, is experiencing acute delirium, and is frequently attempting to pull out their intravenous (IV) catheter. Which interventions should the nurse include in the safety and care plan? Select all that apply.
- Wrap the intravenous insertion site with a loose bandage and cover it with a long-sleeved gown.Cevap
- BUtilize an alcohol-based hand rub for hand hygiene immediately after removing gloves and exiting the room.
- CImplement bilateral soft wrist restraints to secure the client's hands and ensure the intravenous line remains intact.
- Relocate the client to a private room positioned as close to the nursing station as possible for frequent observation.Cevap
- EDelegate the ongoing assessment of the client's orientation and delirium progression to the assigned unlicensed assistive personnel (UAP).
- Provide the client with a washcloth to fold or a safe sensory object to occupy their hands.Cevap
Cevap
The correct interventions are wrapping the IV site and covering it with a long-sleeved gown, relocating the client close to the nursing station, and providing a safe sensory object for distraction.
Protecting the intravenous line by camouflaging it with a loose bandage and long sleeves reduces visual cues that prompt the confused client to pull at it. Relocating the client near the nurses' station enhances surveillance and allows for rapid intervention. Providing a safe sensory object, such as a washcloth to fold, redirects the client's restless energy and keeps their hands occupied. All three actions represent appropriate, non-restrictive safety measures that protect the client without compromising their autonomy or safety.
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Anahtar Kavram
Implementing least restrictive safety measures and appropriate transmission-based precautions while maintaining the RN's responsibility for assessment.