A confused client on a ventilator was restrained to prevent him from p

A confused client on a ventilator was restrained to prevent him from pulling out his endotracheal tube. Which of the following could be a possible alternative measure that the nurse could use to avoid the use of the restraints?

1. Orient the client to the environment and explain the need for the endotracheal tube.
2. Provide a trained sitter to continuously supervise the client.
3. Camouflage the endotracheal tube with stockinette dressing.
4. Promote relaxation techniques.

ANSWER

ANS: 2
A trained sitter can prevent the client from pulling out the endotracheal tube. The client is con-fused and does not understand. The endotracheal tube cannot be camouflaged effectively—the client feels it more than sees it. Because the client is confused, it may be very difficult to com-municate relaxation techniques so that the client has an understanding.