The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take?
a. Assess the patient.
b. Gather restraint supplies.
c. Try alternatives to restraint.
d. Call the health care provider for a restraint order.
ANS: A
When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.
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