The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?

Question

Quizplus · Accepted Answer

A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. (Options B, C, and D) Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action. Educational objective: The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.

The Nurse Cares for a Confused Client Who Continues to Pull