Question

A nurse in an emergency department is caring for a client.

1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardis, hypotensive, ans tachypneic, with weal pulses, and dry mucous membranes, pool turgor, and oliguria. Plan: Admit for IV fluids. VS: T- 101 F, PR- 126/min, Resp - 28/min, BP 92/54 mm Hg, O2 sat 93%.
1900: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated then in situation.

Complete the following sentence by using the list options.
The nurse should first _________ followed by _______.
A) Administer sedative medication immediately, followed by securing restraints.
B) Obtain a prescription from the provider for restraints, followed by padding bony prominences under the restraint.
C) Call security to assist in restraining the client, followed by notifying the provider.
D) Apply restraints without a prescription in order to ensure the client's safety, followed by documenting the incident."

Answer 1

The nurse should obtain a prescription for restraints and then pad bony prominences under the restraint, adhering to protocols and ensuring patient safety and rights.

Step-by-step explanation:

In this clinical scenario, the nurse should prioritize the safety of the patient while following legal and clinical guidelines. The correct action would be B) Obtain a prescription from the provider for restraints, followed by padding bony prominences under the restraint. This ensures the patient's immediate safety while also adhering to required protocols that protect the patient's rights and well-being. It is essential not to apply restraints without a prescription, as this could lead to legal issues, and potentially harm the patient. Furthermore, using a sedative medication is not the first line of action without a proper assessment and order from the provider. The focus is on securing the patient safely and ethically.