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 ["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.
Correct Answer is A
Explanation
Choice A rationale: In the context of influenza, especially during flu seasons, wearing a fitted respirator mask is recommended for healthcare personnel to prevent the spread of respiratory droplets.
Choice B rationale: Instructing the UAP to notify the nurse of respiratory status changes is important but doesn't address the immediate need for proper respiratory protection.
Choice C rationale: Assigning the UAP to another client is not necessary if proper precautions are followed. The focus should be on correcting the current situation.
Choice D rationale: Reviewing the need for the UAP to wear a face mask is insufficient; a fitted respirator mask is more appropriate for respiratory illnesses like influenza.
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