The nurse assesses a client with disseminated intravascular coagulation who is being treated with blood products and heparin.
Which cues indicate worsening organ dysfunction and continued bleeding? Select all that apply.

Delegation requires understanding the scope of practice for unlicensed assistive personnel versus licensed nurses. Tasks involving clinical judgment, titration of medications, or invasive monitoring must be reserved for the registered nurse, while routine, non-invasive tasks can be safely delegated.

Choice A rationale

Central venous pressure monitoring involves an invasive line and requires clinical interpretation of waveforms and readings. This task is beyond the scope of unlicensed personnel and must be performed by a nurse to ensure accuracy and safety.

Choice B rationale

Oral care is a routine hygiene task that falls within the scope of practice for unlicensed assistive personnel. Regular oral care is essential for preventing ventilator-associated pneumonia and maintaining mucosal integrity in critically ill septic patients.

Choice C rationale

While some glucose monitoring can be delegated, hourly measurements in a septic patient typically require clinical titration of insulin or close monitoring of metabolic instability. Agency policies often restrict high-frequency or critical-care monitoring to licensed staff.

Choice D rationale

Titration of vasoactive medications like norepinephrine requires advanced clinical judgment and assessment of hemodynamics. This is a complex nursing intervention that can never be delegated to unlicensed staff due to the high risk of hemodynamic instability.

Choice E rationale

Assessing vital signs in a hemodynamically unstable septic patient involves clinical evaluation. Furthermore, measuring urine output via a catheter in an intensive care setting is often combined with assessing renal perfusion, requiring professional nursing oversight.

Choice F rationale

Measuring and documenting intake and output is a standard technical task delegated to unlicensed personnel. While the nurse must interpret the clinical significance of the balance, the manual collection and recording of data are appropriate delegated duties.

Evaluating pulmonary embolism in patients with renal impairment requires knowledge of contrast-induced nephropathy risks. One must apply understanding of different imaging modalities to select a test that provides diagnostic clarity without using nephrotoxic agents that would worsen kidney failure.

Choice A rationale

Pulmonary angiography is an invasive procedure requiring a large bolus of iodinated contrast. In a client with chronic kidney disease and recent nephropathy, this would likely cause further irreversible damage to the remaining renal function.

Choice B rationale

D-dimer is a screening tool with high sensitivity but low specificity. While it does not require contrast, it cannot definitively diagnose a PE. It is used to rule out PE in low-risk patients rather than confirm.

Choice C rationale

A ventilation-perfusion scan uses radioactive isotopes rather than iodinated contrast. It is the preferred diagnostic test for patients with renal failure because it avoids the risk of contrast-induced nephropathy while effectively assessing for V/Q mismatch.

Choice D rationale

A chest X-ray is useful for ruling out other causes of respiratory distress like pneumonia or pneumothorax, but it is not sensitive or specific enough to diagnose a pulmonary embolism. Most PE patients have normal X-rays..