An older adult who is confused after surgery repeatedly tries to pull at an IV line. Which actions should the nurse try before considering restraints? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Restraints are not first-line interventions. The nurse should use least restrictive measures such as reorientation, closer observation, protecting lines, and treating unmet needs that may worsen agitation. Applying restraints without proper assessment, order, and policy is inappropriate. Isolation in a dark room can increase confusion and safety risk.
Clinical Judgment Confusion plus device pulling calls for safety and need-based interventions before restraint escalation.
Memory Tip Orient, observe, hide tubing, meet needs.
KR vs US NCLEX restraint items emphasize patient rights, least restrictive care, and ongoing assessment.
Clinical Practice GuideCMS patient rights standards emphasize freedom from inappropriate restraint and the need for appropriate restraint use. Nursing practice should begin with least restrictive alternatives whenever possible.
CautionA restraint can increase injury, agitation, skin breakdown, and loss of mobility if used unnecessarily.
Least Restrictive Intervention — The safest intervention that meets the clinical need while limiting the client's freedom as little as possible.
Delirium — An acute change in attention and cognition that can fluctuate and increases safety risk.
Restraint — A device, medication, or method that restricts movement and requires strict indication and monitoring.