The nurse determines that an 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 patient'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 patient about the need to keep the extremity elevated.
The Correct Answer is C
Choice A Reason: Recording the patient's pulse volume distal to the IV site is a nursing assessment that requires clinical judgment and cannot be delegated to the UAP.
Choice B Reason: Reapplying cold compresses to the site of the extravasation is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.
Choice C Reason: Disposing of the IV tubing after the infusion is discontinued is a routine task that does not require clinical judgment and can be delegated to the UAP.
Choice D Reason: Teaching the patient about the need to keep the extremity elevated is a nursing intervention that requires clinical judgment and cannot be delegated to the UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is not the first priority because it does not address the client's safety and well-being. The charge nurse should inform the pharmacist who dispensed the medication, but this can be done later.
Choice B Reason: This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed.
Choice C Reason: This is not the first priority because it does not provide immediate care to the client. The charge nurse should report the medication error to the nursing supervisor, but this can be done later.
Choice D Reason: This is not the first priority because it does not correct the mistake or prevent recurrence. The charge nurse should review the medication transcription with the nurse, but this can be done later.
Correct Answer is A
Explanation
Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.
Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.
Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that
increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.
Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.
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