Difficulty: Medium
Average Score: 71%
Simulated
A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
Correct answer
B
Rationale
The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.