medium · NCLEX-RN Management of Care
The nurse is caring for Marcus, a 21-year-old client with a mild intellectual disability who is recovering on the medical-surgical unit after an uncomplicated orthopedic procedure. Marcus has a court-appointed legal guardian. The guardian is highly protective and demands that the nurse apply bilateral wrist restraints to Marcus to prevent him from accidentally pulling out his peripheral IV line, stating, 'He doesn't understand things and needs to be controlled for his own safety.' Marcus is cooperative, alert, and states, 'I don't want to be tied down. I promise to leave my IV alone.'
Which action should the nurse take first?
- Apply the wrist restraints immediately to honor the legal guardian's direct request and prevent any potential IV dislodgement, in this situation, for the clinical situation described.
- Ask the charge nurse to contact the hospital's legal department to revoke the mother's guardianship because she is being overly restrictive, in this situation, at this point in care.
- Obtain a provider's order for a continuous IV sedative infusion to keep Marcus asleep so that restraints are not necessary.
- Explain to the guardian that restraints require a specific clinical indication and are not used preventatively, and collaborate with Marcus to secure the IV line with a secure sleeve.
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