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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: It is the role of the heathcare provider to provide the patient with explanation for the procedure and ensure their understanding.
Choice B rationale: Postponing the procedure may not be necessary if the client's concerns can be adequately addressed through communication and education. Choice C rationale: Calling the client's next of kin for verbal consent is not appropriate in this situation, as the client is capable of providing informed consent once concerns are addressed.
Choice D rationale: Notifying the healthcare provider isnecessary as it is their role to obtain informed consent. They should also address any patient specific concerns
Correct Answer is D
Explanation
Choice A rationale: Asking the PN to change the sterile dressing while the nurse is busy may compromise patient safety and is not a prudent approach.
Choice B rationale: Reviewing the PN's skill checklist is important, but it may not provide immediate confirmation of the PN's competency in performing sterile wound care.
Choice C rationale: Telling the PN that past experience does not indicate the ability to perform skills may be discouraging and may not directly address the immediate need for a sterile dressing change.
Choice D rationale: Watching the PN perform sterile wound care to validate her skill level is the most direct and immediate way to ensure competency and patient safety.
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