The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
Record the client's pulse volume distal to the IV site every hour.
Reapply cold compresses to the site of the extravasation every hour.
Dispose of the IV tubing after the infusion is discontinued.
Teach the client about the need to keep the extremity elevated.
The Correct Answer is B
Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.
Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.
Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.
Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.
Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.
Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.
Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale: Consulting with the registered dietitian involves clinical judgment and collaboration with another healthcare professional, which is not within the scope of practice for the UAP.
Choice B rationale: Maintaining a clean and pleasant environment during meals is a task that can be delegated to the UAP to enhance the client's dining experience. Choice C rationale: Setting up the food and drink containers within easy reach is a task that the UAP can perform to facilitate the client's access to meals.
Choice D rationale: Offering specific dietary recommendations, such as high-caloric foods, requires knowledge of nutritional needs, which is beyond the UAP's scope. Choice E rationale: Assisting the client with eating small frequent high-calorie meals is a task that can be delegated to the UAP to support the client's nutritional intake.
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