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).

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Evaluating anticoagulants requires interpreting labs like PT/INR and assessing bleeding, a skilled nursing task. Delegation to an assistant is inappropriate, as it demands clinical judgment beyond their scope, involving pharmacokinetics and patient safety monitoring.

Choice B reason: Assisting ambulation promotes venous return, reducing VTE risk via muscle pump action on veins. This physical task aligns with a nursing assistant’s scope, requiring no clinical analysis, making it a safe, effective delegation for prevention.

Choice C reason: Teaching about VTE prevention involves explaining risks and interventions, requiring nursing knowledge of pathophysiology. Assistants lack training for patient education, so this remains an RN duty to ensure accuracy and comprehension.

Choice D reason: Assessing VTE risk and monitoring involve clinical skills like inspecting for swelling or interpreting symptoms. This exceeds an assistant’s scope, as it requires diagnostic reasoning and expertise reserved for licensed nurses.

A. Bradypnea B. Wheezing C. Bradycardia D. Use of accessory muscles for breathing E. Decreased oxygen saturation

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Bradypnea (slow breathing) isn’t typical in asthma exacerbation; tachypnea occurs due to airway obstruction. Reduced respiratory rate suggests fatigue or resolution, not active exacerbation, contradicting the physiology of acute bronchoconstriction.

Choice B reason: Wheezing results from turbulent airflow through narrowed bronchioles in asthma exacerbation. It’s a hallmark sign, reflecting reversible obstruction from inflammation and bronchospasm, consistently present during acute episodes requiring intervention.

Choice C reason: Bradycardia isn’t associated with asthma exacerbation; tachycardia is common from hypoxia and stress. Slow heart rate may indicate severe hypoxia late-stage, but it’s not a typical finding in active exacerbation.

Choice D reason: Accessory muscle use (e.g., sternocleidomastoid) compensates for obstructed airflow in asthma exacerbation. It reflects increased work of breathing due to bronchoconstriction, a frequent physical sign during acute respiratory distress.

Choice E reason: Decreased oxygen saturation occurs in asthma exacerbation from ventilation-perfusion mismatch. Inflamed airways limit oxygen delivery, dropping SpO2 below 95%, a common finding necessitating bronchodilators and oxygen therapy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention for VTE care and prevention can the RN delegate to the nursing assistant?

Correct Answer is B

Explanation

Sara has been admitted to the unit for asthma exacerbation. Which assessment findings are commonly associated with asthma exacerbation? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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