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

Evaluate the effect of anticoagulant drugs by monitoring appropriate laboratory results and side effects of therapy

Help ambulatory patients to walk at least 4 to 6 times daily.

Teach patients at risk for VTE about preventive measures

Assess patients for VTE risk and monitor for VTE in at-risk patients

Answer and Explanation

The Correct Answer is B

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.

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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.

A. I get short of breath when I climb a lot of stairs. B. My fingers hurt when I go outside in cold weather. C. My legs cramp when I walk more than a block. D. When I stand too long, my feet start to swell.

Correct Answer is C

Explanation

Choice A reason: Shortness of breath on stairs suggests cardiopulmonary issues, not intermittent claudication. Claudication is leg pain from arterial insufficiency during activity, not dyspnea, which reflects lung or heart strain.

Choice B reason: Finger pain in cold weather points to Raynaud’s or vasospasm, not claudication. Intermittent claudication affects lower limbs from arterial occlusion, not upper extremities or temperature-related vasomotor changes.

Choice C reason: Leg cramping after walking a block is classic intermittent claudication, from reduced blood flow in peripheral artery disease. Pain with activity, relieved by rest, matches its ischemic pathophysiology perfectly.

Choice D reason: Foot swelling from standing suggests venous stasis or edema, not claudication. Claudication involves arterial insufficiency causing pain with exertion, not fluid accumulation from prolonged static posture.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Which patient statement supports a history of intermittent claudication?

Correct Answer is C

Explanation

Interpret the ABG results: pH: 7.48, PaCO2: 28 mmHg, PaO2: 55 mmHg, HCO3-: 24 mEq/L, SaO2: 87%

A patient comes to the doctor’s office with the following complaints: Moderate to severe pain over the nose, eyes, and forehead, purulent nasal drainage, fever, and malaise. The nurse suspects the patient is suffering from ___________.

Based on the patient’s medication list, which of the following medications directly treat hypertension? (Select all that apply)

A nursing student is reviewing medications used to treat a patient with Peripheral Artery Disease (PAD). Which of the following medications should the nurse identify as commonly prescribed for this condition? (Select all that apply)

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Which nursing intervention is important when providing care for a patient in sickle cell crisis?

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