Directions: Identify the nursing goals/outcome measures for this patient’s heart failure. (Select all that apply)

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.

Choice A reason: Pulmonary edema involves fluid in alveoli, often from heart failure, not directly linked to pancytopenia. Low blood cell counts don’t cause fluid overload; this complication arises from cardiac or renal dysfunction, making it less relevant to pancytopenia’s hematologic deficits.

Choice B reason: Bleeding risk increases with pancytopenia due to thrombocytopenia, reducing platelet counts below 150,000/µL. Impaired clotting leads to spontaneous hemorrhage, such as petechiae or mucosal bleeding, a direct and common consequence of bone marrow suppression in this condition.

Choice C reason: Neurogenic shock results from spinal injury or autonomic dysfunction, causing vasodilation and hypotension. Pancytopenia affects blood cells, not neural regulation, so this complication isn’t a primary risk unless unrelated trauma or systemic failure occurs.

Choice D reason: Infection risk rises with pancytopenia from leukopenia, lowering white blood cells below 4,000/µL. Neutropenia impairs immune defense, increasing susceptibility to bacterial, fungal, or viral infections, a frequent and severe complication requiring vigilant monitoring in these patients.

Choice E reason: Seizures stem from neurologic or metabolic disturbances, like hypoglycemia, not pancytopenia. Reduced blood cells don’t directly affect brain excitability or seizure threshold, making this an unlikely complication unless secondary to infection or bleeding.