The nurse is caring for a client receiving pain medication ...

[dalyningkenk]

The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client?
 
  1. Secure all tubing connections with gauze.
  2. Apply tape over all injection ports on the tubing.
  3. Cleanse the insertion site with alcohol swabs once a day.
  4. Label the tubing, infusion bag, and pump with the word epidural.
  5. Post a sign above the client's bed indicating that an epidural is being used.

Question 2

The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether
 
  1. unlicensed assistive personnel know how to perform a back rub.
  2. there any clients who have intravenous fluids infusing.
  3. there any clients who should not have a back rub performed.
  4. there any clients who are prescribed to take nothing by mouth.
  5. there any clients who do not want a back rub done by unlicensed assistive personnel.

[Sophiapenny]

Answer to Question 1

Correct Answer: 2, 4, 5

Rationale 1: Tubing connections should be secured with tape.

Rationale 2: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter.

Rationale 3: Do not use alcohol in any care of the catheter or insertion site because it can be neurotoxic.

Rationale 4: Label the tubing, the infusion bag, and the front of the pump with tape marked epidural to prevent confusion with similar-looking IV lines.

Rationale 5: Post a sign above the client's bed indicating that an epidural is in place.

Answer to Question 2

Correct Answer: 1, 3, 5
Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for the UAP's comfort and ability.
Rationale 2: An intravenous infusion is not a contraindication for a back rub.
Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications.
Rationale 4: Being prescribed nothing by mouth is not a contraindication for a back rub.
Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate.

[dalyningkenk]

Excellent

[dantucker]

TYSM