A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?
Explanation & Rationale
A. Replacing the IV site with a smaller gauge does not address the issue of the client picking at the dressing and tape. It is important to address the primary concern, which is the integrity of the abdominal incision dressing. B. Applying wrist restraints should be avoided unless absolutely necessary due to the risk of physical and psychological harm to the client. It is not the first-line intervention for addressing dressing and tape disruption. C. Leaving the lights on in the room at night may help reduce confusion in some clients with dementia but does not address the immediate issue of the disrupted abdominal dressing and IV site. D. Redressing the abdominal incision is the priority intervention to maintain the integrity of the surgical site and prevent infection. It also addresses the issue of the client picking at the dressing and tape, which could lead to further complications.