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?
Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.
Set up the automatic noninvasive BP machine to take readings every 15 minutes.
Teach the patient stress-relieving techniques.
Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).
The Correct Answer is C
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: Vasoconstrictors like oxymetazoline shrink vessels, aiding epistaxis control. It’s a secondary step requiring preparation, not first, as direct pressure is faster, non-invasive, and effective for initial hemostasis in most anterior bleeds.
Choice B reason: Packing with a balloon stops severe bleeding but is invasive and later in management. Pressure is the first, simpler action; packing escalates care unnecessarily before basic measures are tried in acute epistaxis.
Choice C reason: Silver nitrate cauterizes vessels, useful for persistent bleeding. It’s not first, requiring setup and assessment after pressure fails, as most epistaxis resolves with compression, making this a subsequent intervention.
Choice D reason: Squeezing nostrils compresses Kiesselbach’s plexus, stopping most anterior nosebleeds within 10 minutes. It’s the immediate, evidence-based first action, non-invasive, and effective, prioritizing rapid control before escalating to other methods.
Correct Answer is C
Explanation
Choice A reason: Wheezing indicates airway narrowing, typical in asthma or COPD, not pneumonia. Pneumonia causes alveolar fluid, producing crackles, so diffuse wheezing doesn’t align with its pathophysiology of consolidation.
Choice B reason: Finger clubbing and pallor suggest chronic hypoxia or anemia, not acute pneumonia. These develop over time, whereas pneumonia presents with acute respiratory signs like crackles, not chronic markers.
Choice C reason: Crackles or rales occur in pneumonia from fluid or pus in alveoli, disrupting airflow. Heard on auscultation, they’re a classic sign, reflecting consolidation or inflammation in affected lung regions.
Choice D reason: Edema is fluid in tissues, linked to heart failure, not pneumonia directly. Pneumonia affects lungs, causing crackles, not peripheral swelling, making this unrelated to typical respiratory findings.
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