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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A reason: Encouraging fluid intake worsens heart failure by increasing preload and congestion. Restriction (e.g., 2L/day) is standard to prevent overload, as excess volume exacerbates dyspnea and edema in compromised hearts.

Choice B reason: Administering diuretics like furosemide reduces fluid overload, easing heart failure symptoms. It lowers pulmonary pressure and edema by enhancing excretion, a critical action to stabilize patients and improve breathing.

Choice C reason: Monitoring weight and fluid balance tracks retention in heart failure; a 2-3 lb gain signals worsening. It guides therapy adjustments, ensuring effective management of volume status and preventing decompensation.

Choice D reason: Educating on low-sodium diets (<2g/day) prevents fluid retention in heart failure. Sodium draws water into vessels, worsening congestion; this empowers patients to control symptoms and supports long-term stability.

A. Cardiac diet B. Cardiac assessment C. Medication education

Correct Answer is C

Explanation

Choice A reason: A cardiac diet (low sodium, low fat) supports blood pressure control long-term by reducing vascular strain. However, it’s less immediate than addressing adherence, as dietary change alone won’t correct current medication misuse driving the elevation.

Choice B reason: Cardiac assessment identifies complications like hypertrophy, useful for monitoring. It’s reactive, not proactive, and doesn’t address the root issue of inconsistent adherence, which directly impacts blood pressure control and outcomes now.

Choice C reason: Medication education tackles adherence, the primary cause of uncontrolled hypertension here. Teaching proper use ensures therapeutic levels, reducing pressure via vasodilation or fluid control, directly improving outcomes with evidence-based efficacy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

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

Explanation

Complete the following sentence: Given the patient’s elevated blood pressure and inconsistent medication adherence, the nurse should prioritize (intervention) to help improve blood pressure control and patient outcome

Correct Answer is C

Explanation

After change-of-shift report, which patient would the nurse assess first?

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?

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is important to communicate to the health care provider?

Which instruction will the nurse plan to include in discharge teaching for a patient who was admitted with a sickle cell crisis?

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2°F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next?

Which finding is the most concerning and should prompt immediate action by the nurse?

The nurse is reviewing the patient’s recent symptoms and lab results. Which of the following symptoms or findings suggest worsening heart failure? (Select all that apply)

An hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage. Which action would the nurse take?