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 A
Explanation
Choice A reason: Ceftriaxone is an antibiotic that can be given by gravity infusion without an IV pump, as long as the nurse monitors the flow rate and adjusts the roller clamp as needed. The dose and duration of ceftriaxone are usually fixed and not affected by minor fluctuations in the infusion rate.
Choice B reason: Heparin is an anticoagulant that requires a precise and constant infusion rate to prevent bleeding or clotting complications. An IV pump is essential to deliver heparin safely and accurately.
Choice C reason: Magnesium is an electrolyte that can cause serious adverse effects such as cardiac arrhythmias,
respiratory depression, and muscle weakness if infused too rapidly or too slowly. An IV pump is necessary to control the infusion rate and prevent magnesium toxicity or deficiency.
Choice D reason: Regular insulin is a hormone that regulates blood glucose levels and requires careful titration based on frequent blood glucose monitoring. An IV pump is required to deliver insulin at a consistent and adjustable rate to avoid hypoglycemia or hyperglycemia.
Correct Answer is D
Explanation
Choice A Reason: Listening for the presence of bowel sounds is not a task that the home health aide can perform, as it requires a stethoscope and clinical judgment. This task is within the scope of practice of the nurse, who should assess the client's bowel function and abdominal status.
Choice B Reason: Teaching the client about foods high in fiber is not a task that the home health aide can perform, as it requires knowledge and education skills. This task is within the scope of practice of the nurse, who should provide dietary advice and counseling to the client and their family.
Choice C Reason: Administering a prescribed dose of a laxative is not a task that the home health aide can perform, as it requires medication administration skills and authority. This task is within the scope of practice of the nurse, who should check the medication order, verify the dosage and route, and document the administration.
Choice D Reason: Assisting the client to drink warm prune juice is a task that the home health aide can perform, as it requires basic care and assistance skills. This task is appropriate for the home health aide, who should encourage fluid intake and offer natural remedies for constipation, such as prune juice, which has laxative effects.
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