The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

Monitor the patient for shortness of breath or chest pain during the transfusion

Obtain the patient's temperature and blood pressure before the transfusion

Double-check the product numbers on the PRBCs with the patient ID band

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring the patient for shortness of breath or chest pain during the transfusion is a critical task that requires nursing judgment and immediate intervention if complications arise. It is not appropriate to delegate this task to unlicensed assistive personnel.

Choice B reason: Obtaining the patient's temperature and blood pressure before the transfusion is a task that can be safely delegated to nursing assistants. This task does not require the clinical judgment of a licensed nurse and is within the scope of practice for unlicensed assistive personnel.

Choice C reason: Double-checking the product numbers on the PRBCs with the patient ID band is a crucial safety step that must be performed by licensed nursing staff. This task ensures the correct blood product is given to the correct patient and involves verification that cannot be delegated to unlicensed personnel.

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Correct Answer is B

Explanation

Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.

Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.

Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.

Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.

A. Warfarin B. Metformin C. Lisinopril

Correct Answer is ["A","B"]

Explanation

Choice A reason: Warfarin should be held before surgery due to its anticoagulant properties. Continuing warfarin increases the risk of excessive bleeding during and after surgery. The patient's INR level is already elevated, indicating a higher risk of bleeding.

Choice B reason: Metformin should be held before surgery, especially for patients undergoing procedures that involve the use of contrast dye or anesthesia. Metformin can cause lactic acidosis in patients with renal impairment or when kidney function is affected by contrast agents or surgery.

Choice C reason: Lisinopril is an ACE inhibitor used to manage blood pressure. While some guidelines suggest holding ACE inhibitors before surgery due to the risk of intraoperative hypotension, this decision is often individualized based on the patient's condition and the type of surgery. It is not as universally indicated to be held as warfarin and metformin.

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The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

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Naxlex Comprehensive Predictor Exams

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

Correct Answer is B

Explanation

Correct Answer is ["A","B"]

Explanation

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