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: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.
Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.
Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.
Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.
Correct Answer is C
Explanation
Choice A rationale: This statement is inaccurate. Managed healthcare plans typically cover in-hospital medical evaluations, but the decision may be subject to precertification requirements.
Choice B rationale: While grief is a natural response to the loss of a spouse, the client's confusion and disorientation warrant a medical evaluation, and this option dismisses the family's concerns.
Choice C rationale: Managed care providers often have mandatory precertification requirements for hospitalization. Informing the family about this requirement is important for them to navigate the process effectively.
Choice D rationale: This statement does not provide relevant information about the managed healthcare plan's policies or the client's current condition.
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