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 D
Explanation
Choice A Reason: This is not the first priority because it does not address the client's immediate needs. The nurse should obtain the client's legal records for power of attorney, but this can be done later.
Choice B Reason: This is a good action because it helps relieve the client's pain and discomfort. The nurse should give analgesic medications as needed (PRN), but this is not enough to meet the client's holistic needs.
Choice C Reason: This is not an appropriate action because it may cause harm to the client. The nurse should not discontinue the intravenous infusion without a valid reason and a healthcare provider's order.
Choice D Reason: This is the best action because it respects the client's wishes and provides him with quality end-of-life care. The nurse should ask the palliative care team to speak with the client and offer him emotional, spiritual, and physical support.
Correct Answer is A
Explanation
Choice A Reason: This is the correct answer because the acuity level of the clients reflects their complexity and intensity of care needs. The higher the acuity level, the more time and resources are required to provide safe and quality care. The charge nurse should consider the acuity level of the clients when determining the appropriate nurse-to-client ratio and staffing needs.
Choice B Reason: The physicians' plans to perform procedures on the unit is not the most important information for the charge nurse to consider because it does not directly affect the nursing workload or staffing requirements. The charge nurse should coordinate with the physicians and other departments to ensure that the procedures are scheduled and performed safely and efficiently.
Choice C Reason: The number of clients leaving the unit for diagnostic tests is not the most important information for the charge nurse to consider because it does not indicate the level of care that the clients need or receive. The charge nurse should ensure that the clients are prepared and accompanied for their tests and that their care is continued and monitored on their return.
Choice D Reason: The skill level of the personnel staffing the unit is not the most important information for the charge nurse to consider because it does not reflect the actual demand or supply of nursing care. The charge nurse should assign and delegate tasks according to the personnel's skill level and scope of practice but also consider other factors such as client acuity, availability, and preference.
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