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: Directing the UAP to delay weighing the client might not address the underlying issue. Understanding the client's refusal is essential for appropriate interventions.
Choice B rationale: Documenting that the client refused daily weights is important for documentation purposes, but it doesn't address the issue or provide information on the client's fluid status.
Choice C rationale: Instructing the UAP to weigh the client using a bed scale is a good option, but understanding the client's concerns or reasons for refusal is important for effective communication and addressing potential issues.
Choice D rationale: Asking the client why he does not want to be weighed is essential for understanding and addressing the client's concerns. It allows the nurse to provide education, reassurance, or alternative solutions to ensure the client's cooperation with the prescribed care plan.
Correct Answer is A
Explanation
Choice A rationale: The priority is to ensure the client's safety and comfort. If the client is restrained for bed linen change, alternative methods that don't involve wrist restraints should be considered. The nurse manager should advise the staff nurse to remove the restraints promptly.
Choice B rationale: Determining whether the client has a PRN prescription for an antianxiety agent is not the priority in this situation. The immediate concern is the use of restraints for a non-emergency purpose.
Choice C rationale: Contacting the healthcare provider to ensure a prescription for restraints was written may be needed, but the immediate concern is addressing the use of restraints for changing bed linens.
Choice D rationale: Closing the door to the room to avoid disturbing other clients is not the priority in this situation. The primary concern is the use of restraints for a non emergency purpose.
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