# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393833&lang=en  
> language: en  
> subject: Use of Restraints/Safety Devices  
> category: SIPC

## Question

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.

1

Assess and address pain, toileting needs, hunger, or discomfort.

2

Move the client closer to the nurses' station or increase observation.

3

Apply wrist restraints immediately without a provider order.

4

Reorient the client and explain the purpose of the IV line.

5

Turn off lights, close the door, and leave the client alone to rest.

6

Conceal or protect the IV tubing when possible.

## 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.

## In-depth explanation

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 scenario

Clinical Practice Guide
CMS 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.

Caution
A restraint can increase injury, agitation, skin breakdown, and loss of mobility if used unnecessarily.

## Key concepts

- **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.

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