Question

During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom).

1.Assess the client’s skin and circulation for impairment related to the restrains
2.Evaluate the client’s mentation to determine need to continue the restrains
3.Assign unlicensed assistive personnel to remove restrains and remain with client
4.Contact the client’s surgeon and primary healthcare provider

Answer 1

The nurse should first evaluate the client's mental state to determine the need for restraints, then assess his skin and circulation. After these assessments, the nurse can task assistive personnel to remove the restraints and stay with the client before contacting the healthcare provider and surgeon.

Step-by-step explanation:

Upon receiving the report of a disoriented male client who required restraint after surgery, the nurse should prioritize the sequence of actions that will ensure the patient's safety and address his current mental and physical condition. The interventions, arranged from first to last action, should be as follows:

1. Evaluate the client's mentation to determine the need to continue the restraints.
2. Assess the client's skin and circulation for impairment related to the restraints.
3. Assign unlicensed assistive personnel to remove restraints and remain with the client.
4. Contact the client's surgeon and primary healthcare provider for further instructions and to report the client's status.