Question

Mr. Emery has fluids running. The novice nurse is delegating tasks to the unlicensed assistive personnel (UAP). In which instance(s) will the nurse intervene? (Select all that apply). 1. "Let me know if the client reports pain at the IV site." 2. "Let me know if the client develops pitting edema." 3. "Let me know if the IV dressing becomes wet or loose." 4. "Let me know if the client has crackles upon auscultation." 5. "Let me know if the electronic infusion pump starts alarming." Scoring:

Answer 1

The nurse should intervene if the client reports pain at the IV site, develops pitting edema, or if the IV dressing becomes wet or loose.

Step-by-step explanation:

The nurse should intervene in the following instances:

1. 'Let me know if the client reports pain at the IV site.' This is important because pain at the IV site could indicate inflammation or infection.
2. 'Let me know if the client develops pitting edema.' Pitting edema can indicate fluid overload or heart failure and requires medical attention.
3. 'Let me know if the IV dressing becomes wet or loose.' A wet or loose IV dressing can increase the risk of infection and should be addressed.

The remaining options do not require immediate intervention from the nurse. Crackles upon auscultation may indicate fluid in the lungs, but this does not require immediate action from the nurse. Similarly, an electronic infusion pump alarming may be a technical issue but does not directly affect the client's well-being.