An older female adult who receives intravenous (IV) fluids is making wide gesticulations with her arms and insulting the nursing staff loudly. 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 agitation.
c. Close the door to her room to reduce the noise.
d. Pad the arm to prevent elbow and wrist flexion.

Answer 1

D

Feedback
A Incorrect. Restraining one side creates a potential threat from the other arm to the integrity of the IV, but bilateral restraints can be justified for the protection of the IV site. However, as a first step, padding the arm is a better preventive measure because the padding allows from some movement and prevents the pa-tient from manipulating the IV site.
B Incorrect. Administration of an antipsychotic agent can be justified for agitation but is not in this case, because less intrusive measures are available for initial protective measures.
C Incorrect. Although nurses tend to keep the doors of patients' and residents' rooms slightly ajar to maintain privacy, closing this woman's door is contrain-dicated to control noise because it can contribute to the risk of falls and injury and does nothing to maintain the integrity of the IV.
D Correct. To help maintain her independence and permit the administration of IV fluids yet provide safe, effective care, the nurse protects the IV insertion site with thick padding. This will prevent flexion at the elbow and wrist but allow free movement at the shoulder. Also, padding the IV site protects it against bumps from her movements and prevents manipulation of the IV by her other hand.