Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Show the caregiver how to check the patient’s temperature and blood pressure.

Give the patient a pamphlet that reinforces teaching done by the nurse.

Evaluate whether the patient and caregiver understand the teaching.

Plan topics for the discharge teaching session with the patient and caregiver.

Answer and Explanation

The Correct Answer is A

Choice A: Show the caregiver how to check the patient’s temperature and blood pressure
Showing the caregiver how to check the patient’s temperature and blood pressure involves direct patient education and demonstration, which requires the clinical judgment and expertise of a licensed nurse. This task ensures that the caregiver understands the correct techniques and can accurately monitor the patient’s vital signs. Delegating this task to assistive personnel (AP) is not appropriate because it requires a higher level of skill and knowledge to teach and verify understanding.
Choice B: Give the patient a pamphlet that reinforces teaching done by the nurse
Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.
Choice C: Evaluate whether the patient and caregiver understand the teaching
Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.
Choice D: Plan topics for the discharge teaching session with the patient and caregiver
Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Notifying the oncologist or healthcare provider immediately is crucial in the event of a reaction or side effect during chemotherapy. Prompt communication with the healthcare provider ensures that the patient receives appropriate and timely medical intervention. The oncologist can provide specific instructions on managing the reaction, including any necessary medications or adjustments to the chemotherapy regimen. Immediate notification helps in preventing the escalation of the reaction and ensures patient safety.

Choice B reason:

Slowing the chemotherapy infusion is not typically recommended as an immediate intervention for a severe reaction. While adjusting the infusion rate can be considered for mild reactions, it is not sufficient for managing more serious side effects or hypersensitivity reactions. In cases of significant reactions, stopping the infusion and taking other emergency measures are more appropriate. Slowing the infusion might delay the necessary interventions and could potentially worsen the patient’s condition.

Choice C reason:

Stopping the chemotherapy infusion is a critical step in managing a reaction. Halting the infusion immediately prevents further exposure to the causative agent, which can help in stabilizing the patient’s condition. This action is essential to prevent the reaction from worsening and allows time for the healthcare team to assess the situation and implement appropriate interventions. Stopping the infusion is a standard protocol in managing infusion-related reactions.

Choice D reason:

Assessing Ms. Anderson’s vital signs and symptoms is essential to determine the severity of the reaction and guide further interventions. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation provides crucial information about the patient’s physiological status. This assessment helps in identifying any life-threatening changes and ensures that appropriate measures are taken to stabilize the patient. Continuous monitoring is vital for detecting any deterioration in the patient’s condition.

Choice E reason:

Infusing normal saline at 100 ml/hr is an important intervention to maintain intravenous access and provide fluid support. Normal saline helps in stabilizing the patient’s blood pressure and improving circulation, which can be compromised during a severe reaction. It also ensures that the IV line remains patent for the administration of emergency medications if needed. Fluid support is a key component of managing infusion-related reactions and preventing complications.

A. Monitor the CXR results. B. Monitor the BMP, especially the sodium, potassium, and magnesium counts. C. Monitor the CBC, especially the neutrophil, platelet, and RBC counts. D. Monitor the spinal fluid analysis.

Correct Answer is C

Explanation

Choice A Reason:
Monitoring the CXR (chest X-ray) results is not directly related to assessing myelosuppression. A chest X-ray is typically used to evaluate the lungs and heart, and while it can help identify infections or other complications, it does not provide information about bone marrow activity or blood cell counts. Myelosuppression specifically affects the production of blood cells in the bone marrow, which is best assessed through blood tests like the CBC (Complete Blood Count).
Choice B Reason:
Monitoring the BMP (Basic Metabolic Panel), especially the sodium, potassium, and magnesium counts, is important for evaluating electrolyte balance and kidney function. However, it does not directly assess myelosuppression. Myelosuppression involves the suppression of bone marrow activity, leading to decreased production of blood cells, which is not reflected in electrolyte levels.
Choice C Reason:
Monitoring the CBC (Complete Blood Count), especially the neutrophil, platelet, and RBC (red blood cell) counts, is the most appropriate method for assessing myelosuppression. Myelosuppression results in decreased production of blood cells, including neutrophils (a type of white blood cell), platelets, and red blood cells. A CBC provides detailed information about these cell counts and helps identify conditions like neutropenia (low neutrophil count), thrombocytopenia (low platelet count), and anemia (low red blood cell count), which are common consequences of myelosuppression.
Choice D Reason:
Monitoring the spinal fluid analysis is not relevant for assessing myelosuppression. Spinal fluid analysis is typically used to diagnose conditions affecting the central nervous system, such as infections, bleeding, or multiple sclerosis. It does not provide information about bone marrow activity or blood cell counts, which are the primary concerns in myelosuppression.

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Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The next 3 questions relate to this case study: Exhibits In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

Correct Answer is C

Explanation

A patient with alkalosis can develop hyperkalemia.

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