A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?

Ask the Health Care Provider to order a sweat chloride test.

Coordinate with the dietitian to place the patient on a low-sodium diet.

Coordinate with respiratory therapy to perform chest physiotherapy

Coordinate with the case manager to arrange for a hospice nurse visit.

Answer and Explanation

The Correct Answer is C

Choice A reason: Sweat chloride tests diagnose CF, not manage dyspnea in a known patient. It’s irrelevant here, as the focus is treating acute respiratory symptoms, not reconfirming an established diagnosis in this scenario.

Choice B reason: Low-sodium diets aren’t indicated for CF; patients need high salt due to losses. Dyspnea stems from mucus obstruction, not fluid, so this intervention contradicts CF physiology and symptom management.

Choice C reason: Chest physiotherapy clears mucus in CF, improving airflow and reducing dyspnea. It targets the primary cause—thick secretions—enhancing lung function, a standard intervention coordinated with respiratory therapy for acute exacerbations.

Choice D reason: Hospice is premature for dyspnea in CF without end-stage decline. It’s inappropriate now, as active interventions like physiotherapy address reversible symptoms, prioritizing treatment over palliative care planning.

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Correct Answer is B

Explanation

Choice A reason: Evaluating anticoagulants requires interpreting labs like PT/INR and assessing bleeding, a skilled nursing task. Delegation to an assistant is inappropriate, as it demands clinical judgment beyond their scope, involving pharmacokinetics and patient safety monitoring.

Choice B reason: Assisting ambulation promotes venous return, reducing VTE risk via muscle pump action on veins. This physical task aligns with a nursing assistant’s scope, requiring no clinical analysis, making it a safe, effective delegation for prevention.

Choice C reason: Teaching about VTE prevention involves explaining risks and interventions, requiring nursing knowledge of pathophysiology. Assistants lack training for patient education, so this remains an RN duty to ensure accuracy and comprehension.

Choice D reason: Assessing VTE risk and monitoring involve clinical skills like inspecting for swelling or interpreting symptoms. This exceeds an assistant’s scope, as it requires diagnostic reasoning and expertise reserved for licensed nurses.

A. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. B. Set up the automatic noninvasive BP machine to take readings every 15 minutes. C. Teach the patient stress-relieving techniques. D. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).

Correct Answer is C

Explanation

Choice A reason: Titrating nitroprusside requires adjusting IV infusion based on MAP, a skilled nursing task. Assistants can’t perform this, as it involves pharmacology and critical judgment beyond their scope in a crisis.

Choice B reason: Setting up a BP machine to monitor every 15 minutes is a technical task within an assistant’s role. It requires no interpretation, supporting the RN’s management of hypertensive crisis safely and effectively.

Choice C reason: Teaching stress relief demands nursing expertise in patient education and psychology. Assistants lack training to deliver this, making it an RN duty to ensure comprehension and relevance in care.

Choice D reason: Evaluating nitroprusside’s effect involves analyzing BP trends and drug response, a clinical skill. Delegation is inappropriate, as assistants can’t assess therapeutic outcomes or adjust care in this critical scenario.

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A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention for VTE care and prevention can the RN delegate to the nursing assistant?

Correct Answer is B

Explanation

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced nursing assistant?

Correct Answer is C

Explanation

The nurse is preparing to assess Maria’s respiratory system. Which assessment findings are likely to be associated with pneumonia?

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