During the care of a breast cancer patient, which delegation action should a nurse prioritize?
Delegate the administration of chemotherapy to a newly hired nursing assistant under supervision.
Delegate the task of monitoring vital signs to a qualified nursing student after providing appropriate direction.
Instruct a licensed practical nurse (LPN) to educate the patient about potential side effects of radiation therapy.
Assign the task of performing assessments on the patient's condition to a family member.
The Correct Answer is B
Choice A rationale
Administering chemotherapy involves the handling of highly toxic cytotoxic agents that require specialized certification and advanced clinical knowledge. Nursing assistants do not possess the legal scope of practice or the pharmacological training to manage these medications, even under direct supervision. Prioritizing this delegation would violate safety protocols and state nurse practice acts, as the risk of extravasation or systemic toxicity requires continuous assessment by a registered nurse.
Choice B rationale
Monitoring vital signs is a technical task that falls within the competency of a nursing student who has received proper instruction. The registered nurse remains responsible for interpreting these values, but delegating the collection of data allows for efficient workflow. Vital signs provide critical data on the hemodynamic stability of a cancer patient, and a qualified student can accurately perform this task once they have demonstrated clinical proficiency in a controlled environment.
Choice C rationale
Patient education regarding the complex side effects of radiation therapy is a core responsibility of the registered nurse that cannot be delegated to a licensed practical nurse. Radiation involves intricate physiological changes, such as skin integrity breakdown and internal tissue inflammation, requiring a high level of clinical judgment. While an LPN can reinforce teaching, the initial assessment of learning needs and the development of the educational plan must be performed by the professional nurse.
Choice D rationale
Performing clinical assessments is a non-delegable task that requires professional diagnostic reasoning and specialized medical knowledge. Family members can provide subjective information regarding a patient's comfort or history, but they lack the objective clinical training required to evaluate physical symptoms or disease progression. Assigning assessment tasks to unlicensed individuals who are not healthcare professionals compromises patient safety and leads to inaccurate data collection regarding the patient's oncological status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The T component of the TNM staging system is scientifically designed to evaluate the primary tumor site. This assessment includes measuring the size of the tumor in centimeters and determining the degree of invasion into adjacent anatomical structures. For example, a higher T numerical value suggests a larger tumor or one that has penetrated deeper into the surrounding tissues. This information is critical for clinicians to understand the local burden of the disease and plan surgical interventions.
Choice B rationale
The N component specifically assesses the involvement of regional lymph nodes by the cancer cells. This part of the staging system documents whether the malignancy has migrated from the primary site to nearby nodes, which serve as common pathways for cancer spread. A classification of N0 indicates no nodal involvement, while N1, N2, or N3 reflect increasing numbers or distances of affected nodes. Identifying nodal status is essential for determining the necessity of adjuvant therapies like radiation or chemotherapy.
Choice C rationale
The M component stands for metastasis and is used to identify whether the cancer has spread to distant organs or tissues far from the primary tumor. This is a binary or tiered assessment where M0 indicates no distant spread and M1 indicates the presence of distant metastases. Understanding the metastatic status is perhaps the most vital part of staging, as it fundamentally shifts the treatment goal from curative intent to palliative care or systemic management of the disease.
Choice D rationale
While the TNM staging system provides a detailed snapshot of the cancer's anatomical extent at the time of diagnosis, it is not primarily used to measure the response to initial treatment. Assessing treatment response typically involves follow-up imaging, biopsy, or tumor marker analysis to compare the status of the cancer before and after therapy. The TNM system is a diagnostic and prognostic tool utilized to establish a baseline and determine the most appropriate initial clinical management strategy. .
Correct Answer is B
Explanation
Choice A rationale
Elevated blood glucose and increased appetite are side effects of chronic glucocorticoid therapy rather than signs of acute adrenal insufficiency. Cortisol normally stimulates gluconeogenesis and antagonizes insulin; therefore, an excess causes hyperglycemia. In acute insufficiency, the opposite occurs: glucose levels typically drop below 70 mg/dL because there is insufficient cortisol to maintain carbohydrate metabolism. Increased appetite is a classic sign of Cushing's syndrome or steroid-induced polyphagia, not an acute adrenal crisis.
Choice B rationale
Fatigue, weakness, and dizziness are early clinical manifestations of an addisonian crisis resulting from severe cortisol and aldosterone depletion. These symptoms occur due to a combination of hypoglycemia and decreased cardiac output. As fluid volume decreases and blood pressure drops, the brain and muscles receive inadequate perfusion, leading to profound lethargy. Monitoring for these signs is vital when a patient begins hydrocortisone, as it may indicate that the dosage is insufficient to meet the body's metabolic demands.
Choice C rationale
Increased blood pressure and tachycardia are not typical of acute adrenal insufficiency; rather, hypotension is the hallmark sign. While tachycardia can occur as a compensatory mechanism for low stroke volume, the lack of mineralocorticoids usually prevents the body from maintaining a high blood pressure. In a crisis, the systolic blood pressure often falls below 90 mmHg. If a patient displays hypertension, it is more likely an indication of over-replacement of steroids or another unrelated cardiovascular condition.
Choice D rationale
Fluid retention and hypertension are symptoms of mineralocorticoid excess, often seen in conditions like primary aldosteronism or as a side effect of excessive hydrocortisone administration. Acute adrenal insufficiency is characterized by the massive loss of water and sodium through the kidneys, leading to profound hypovolemia and vascular collapse. Normal blood pressure is roughly 120/80 mmHg; in insufficiency, these values decrease significantly. Therefore, the nurse should be looking for signs of dehydration and low blood pressure instead. .
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