The next 3 questions relate to this case study:

Exhibits

In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Choice A reason:

Notifying the oncologist or healthcare provider immediately is crucial in the event of a reaction or side effect during chemotherapy. Prompt communication with the healthcare provider ensures that the patient receives appropriate and timely medical intervention. The oncologist can provide specific instructions on managing the reaction, including any necessary medications or adjustments to the chemotherapy regimen. Immediate notification helps in preventing the escalation of the reaction and ensures patient safety.

Choice B reason:

Slowing the chemotherapy infusion is not typically recommended as an immediate intervention for a severe reaction. While adjusting the infusion rate can be considered for mild reactions, it is not sufficient for managing more serious side effects or hypersensitivity reactions. In cases of significant reactions, stopping the infusion and taking other emergency measures are more appropriate. Slowing the infusion might delay the necessary interventions and could potentially worsen the patient’s condition.

Choice C reason:

Stopping the chemotherapy infusion is a critical step in managing a reaction. Halting the infusion immediately prevents further exposure to the causative agent, which can help in stabilizing the patient’s condition. This action is essential to prevent the reaction from worsening and allows time for the healthcare team to assess the situation and implement appropriate interventions. Stopping the infusion is a standard protocol in managing infusion-related reactions.

Choice D reason:

Assessing Ms. Anderson’s vital signs and symptoms is essential to determine the severity of the reaction and guide further interventions. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation provides crucial information about the patient’s physiological status. This assessment helps in identifying any life-threatening changes and ensures that appropriate measures are taken to stabilize the patient. Continuous monitoring is vital for detecting any deterioration in the patient’s condition.

Choice E reason:

Infusing normal saline at 100 ml/hr is an important intervention to maintain intravenous access and provide fluid support. Normal saline helps in stabilizing the patient’s blood pressure and improving circulation, which can be compromised during a severe reaction. It also ensures that the IV line remains patent for the administration of emergency medications if needed. Fluid support is a key component of managing infusion-related reactions and preventing complications.

Choice A reason:

Instructing the client to hold a pillow to the abdominal incision when coughing is a task that involves patient education and reinforcement of postoperative care techniques. While LPNs/LVNs can provide basic patient education, this specific task requires ensuring that the patient understands the importance of splinting the incision to reduce pain and prevent complications such as wound dehiscence. This level of instruction is typically within the scope of practice for a registered nurse (RN), who has more extensive training in patient education and postoperative care. Therefore, this task is not the most appropriate for delegation to an LPN/LVN.

Choice B reason:

Obtaining bedside blood glucose is a task that is appropriate for delegation to an LPN/LVN. LPNs/LVNs are trained to perform routine tasks such as monitoring vital signs, including blood glucose levels, especially in patients with diabetes. This task involves using a glucometer to measure the patient’s blood sugar levels and recording the results. It does not require complex clinical judgment, making it suitable for an LPN/LVN. Regular monitoring of blood glucose is crucial for managing diabetes and preventing complications such as hyperglycemia or hypoglycemia.

Choice C reason:

Creating the plan of care is a complex task that involves comprehensive assessment, critical thinking, and clinical judgment. This task is typically within the scope of practice for an RN, who is trained to develop and implement individualized care plans based on a thorough assessment of the patient’s needs, medical history, and current condition. The RN collaborates with other healthcare team members to ensure that the care plan addresses all aspects of the patient’s recovery and health maintenance. LPNs/LVNs can contribute to the care plan by providing input and performing delegated tasks, but they do not have the authority to create the plan of care independently.

Choice D reason:

Documenting postoperative teaching involves recording the education provided to the patient about their postoperative care, including instructions on medication, activity restrictions, wound care, and signs of complications to watch for. This task requires ensuring that the patient understands the information and can follow the instructions correctly. While LPNs/LVNs can reinforce teaching and provide basic education, the initial comprehensive teaching and documentation are typically the responsibility of an RN. The RN ensures that the teaching is thorough and that the patient has the necessary knowledge to manage their care at home.