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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason: Metabolic alkalosis shows pH >7.45 with HCO3- >26 mEq/L from base excess. Here, pH is 7.48, but HCO3- is normal at 24 mEq/L, ruling out metabolic cause. PaO2 of 55 mmHg indicates hypoxemia, but the primary issue isn’t metabolic.
Choice B reason: Respiratory alkalosis occurs with pH >7.45 and PaCO2 <35 mmHg from hyperventilation. Here, pH is 7.48, PaCO2 is 28 mmHg, and HCO3- is normal, confirming respiratory etiology. PaO2 of 55 mmHg shows hypoxemia, matching this acute ventilatory pattern.
Choice C reason: Metabolic acidosis has pH <7.35 and HCO3- <22 mEq/L from acid gain. Here, pH is 7.48 and HCO3- is 24 mEq/L, contradicting acidosis. PaO2 of 55 mmHg indicates hypoxemia, but the acid-base status is alkalotic, not acidic.
Choice D reason: Respiratory acidosis features pH <7.35 and PaCO2 >45 mmHg from CO2 retention. Here, pH is 7.48 and PaCO2 is 28 mmHg, showing CO2 loss, not retention. Hypoxemia (PaO2 55 mmHg) is present, but the pattern is alkalotic.
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