Question

A client is receiving chemotherapy and reports that the tubing has pulled apart and notices a puddle on the floor. Which of the following is the priority nursing action to take after ensuring the client is stable and appropriate tubing disposal?

1) Assess the client for any signs of infection
2) Notify the healthcare provider immediately
3) Clean up the spill using appropriate precautions
4) Document the incident in the client's medical record

Answer 1

The priority nursing action to take after ensuring the client is stable and appropriate tubing disposal is to assess the client for any signs of infection. Chemotherapy can weaken the immune system, making the client more susceptible to infections. By assessing for signs of infection, such as fever, redness, warmth, or swelling at the site of the tubing separation, the nurse can identify any potential complications and intervene promptly.

Step-by-step explanation:

The priority nursing action to take after ensuring the client is stable and appropriate tubing disposal is to assess the client for any signs of infection.

Chemotherapy can weaken the immune system, making the client more susceptible to infections. By assessing for signs of infection, such as fever, redness, warmth, or swelling at the site of the tubing separation, the nurse can identify any potential complications and intervene promptly.

After assessing for infection, the nurse should also notify the healthcare provider, as this is an important safety issue that requires their attention. Cleaning up the spill using appropriate precautions is necessary to prevent further spread of any hazardous substances. Finally, documenting the incident in the client's medical record ensures that there is a record of what happened and any actions taken.