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 A
Explanation
Choice A rationale: Conducting a closer examination of staff nurses' distribution of pain medication is the first step to identify any issues or patterns contributing to the higher than-usual administration of narcotic pain medications.
Choice B rationale: Holding a mandatory staff meeting may be necessary, but a focused examination should precede broader discussions.
Choice C rationale: Questioning clients about the effectiveness of pain medication is an important aspect of the investigation but should follow a thorough examination of medication distribution.
Choice D rationale: Discussing with the healthcare provider about changing client analgesia may be considered later based on the findings of the examination.
Correct Answer is B
Explanation
Choice A rationale: Discussing with the family about placing the client in a skilled care facility may be a consideration, but it's not the most immediate concern. Choice B rationale: Determining if the client is manifesting other neurologic changes is crucial to identify potential complications or underlying issues causing the agitation.
Choice C rationale: Requesting family members to report when the client is left alone is important for safety but doesn't address the immediate assessment of the client's condition.
Choice D rationale: Applying a restraining device to prevent the client from self-injury is not the first choice and should only be considered if there's an immediate threat to the client's safety or the safety of others.
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