NCLEX-RNSafety and Infection Prevention and ControlMedium
A nurse is caring for a client who suddenly becomes agitated and attempts to remove their intravenous (IV) line. The client has a history of dementia and is disoriented. After attempting verbal de-escalation without success, which action should the nurse take next?
- AAssign a staff member to provide one-on-one observation.
- BApply soft wrist restraints immediately to prevent IV removal.
- CDocument the incident and continue to monitor the client closely.
- DRequest a physician's order for chemical restraints.
Show answer & explanationAnswer & explanation
Correct answer: A. Assign a staff member to provide one-on-one observation.
When a client is agitated and at risk of self-harm or interfering with medical treatment, and verbal de-escalation fails, the least restrictive intervention should be attempted first. One-on-one observation can often prevent harm without resorting to physical or chemical restraints, which have strict guidelines and potential adverse effects.
Why the other options are wrong
- B. Physical restraints should be a last resort, after less restrictive measures have failed, and require a physician's order and specific protocols.
- C. Simply documenting and monitoring without active intervention is insufficient when the client is actively attempting to remove a necessary medical device.
- D. Chemical restraints are also a form of restraint and should be considered after less restrictive measures, and require a physician's order.
Restraint Alternatives
Interventions used to prevent harm or manage behavior without applying physical or chemical restraints.
- Prioritize least restrictive measures.
- Includes reorientation, diversion, close observation.
- Aims to maintain client dignity and autonomy.
Memory trick: Calm the Storm, Less Restrictive is the Norm.