An older woman who receives intravenous (IV) fluids is making wide gesticulations with her arms and loudly insulting the nursing staff. Which intervention should the nurse implement to maintain safe, effective nursing care initially?

Question

a. Apply bilateral upper extremity restraints.
b. Administer haloperidol (Haldol) for agita-tion.
c. Close the door to her room to reduce the noise.
d. Determine the patients needs.

Answer 1

D
To help maintain her independence and permit the administration of IV fluids yet provide safe, effective care, the nurse should determine what the patient is attempting to convey and then ad-dress those needs. Restraining one side creates a potential threat from the other arm to the inte-grity of the IV, but bilateral restraints can be justified for the protection of the IV site. However, as a first step, the nurse should determine if the patient has a need that has not been met before moving to a restraint.
Administering an antipsychotic agent can be justified for agitation but not in this patient. Less intrusive measures are available for initial protective measures. Although nurses tend to keep the doors of patients' and residents' rooms slightly ajar to maintain privacy, closing this woman's door is contraindicated to control noise because it can contribute to the risk of falls and injury and does nothing to maintain the integrity of the IV.