The intensive care nurse is caring for a client with sepsis.
Which interventions can the nurse delegate to the unlicensed assistive personnel? Select All that Apply.

Obtain CVP reading.

Provide oral care at least q hr.

Obtain hourly capillary blood glucose measurements per agency policy.

Titrate norepinephrine infusion rates based on patient's systolic blood pressure readings.

Obtain hourly vital signs, including urinary output.

Measure and document I and O.

Answer and Explanation

Correct Answer : B,F

Delegation requires understanding the scope of practice for unlicensed assistive personnel versus licensed nurses. Tasks involving clinical judgment, titration of medications, or invasive monitoring must be reserved for the registered nurse, while routine, non-invasive tasks can be safely delegated.

Choice A rationale

Central venous pressure monitoring involves an invasive line and requires clinical interpretation of waveforms and readings. This task is beyond the scope of unlicensed personnel and must be performed by a nurse to ensure accuracy and safety.

Choice B rationale

Oral care is a routine hygiene task that falls within the scope of practice for unlicensed assistive personnel. Regular oral care is essential for preventing ventilator-associated pneumonia and maintaining mucosal integrity in critically ill septic patients.

Choice C rationale

While some glucose monitoring can be delegated, hourly measurements in a septic patient typically require clinical titration of insulin or close monitoring of metabolic instability. Agency policies often restrict high-frequency or critical-care monitoring to licensed staff.

Choice D rationale

Titration of vasoactive medications like norepinephrine requires advanced clinical judgment and assessment of hemodynamics. This is a complex nursing intervention that can never be delegated to unlicensed staff due to the high risk of hemodynamic instability.

Choice E rationale

Assessing vital signs in a hemodynamically unstable septic patient involves clinical evaluation. Furthermore, measuring urine output via a catheter in an intensive care setting is often combined with assessing renal perfusion, requiring professional nursing oversight.

Choice F rationale

Measuring and documenting intake and output is a standard technical task delegated to unlicensed personnel. While the nurse must interpret the clinical significance of the balance, the manual collection and recording of data are appropriate delegated duties.

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Correct Answer is A

Explanation

Neurological posturing indicates severe brain injury and helps localize the level of damage. Applying knowledge of motor pathway dysfunction, specifically the corticospinal tract, is necessary to distinguish between flexion and extension patterns seen in comatose patients.

Choice A rationale

Decorticate posturing results from damage to the corticospinal tract above the red nucleus. It is characterized by adduction of the arms, internal rotation, and flexion at the elbows, wrists, and fingers, while legs are extended and internally rotated.

Choice B rationale

This description does not match a standard neurological posturing pattern. Rigidity and flexion are seen in decorticate posturing, but "back hunched over" and "supination" of arms are not typical descriptors for these specific upper motor neuron indicators.

Choice C rationale

Supination of the arms is not a component of pathological posturing. Both decorticate and decerebrate posturing typically involve some form of pronation or flexion. Dorsiflexion is also not standard, as plantar flexion is commonly seen in both.

Choice D rationale

This describes decerebrate posturing, which indicates more severe damage to the brainstem or midbrain. It is characterized by rigid extension of the arms and legs, pronation of the arms, and plantar flexion of the feet with outward rotation.

A. Increased Amylase. B. Decreased calcium related to binding of calcium. C. Increased Lipase. D. Decreased serum glucose. E. Elevated serum calcium.

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

Explanation

Chronic pancreatitis involves long-term inflammation of the pancreas leading to permanent structural damage and functional impairment. Knowledge of pancreatic enzyme dynamics, calcium sequestration during fat necrosis, and the resulting endocrine dysfunction is essential to identify clinical manifestations and laboratory abnormalities.

Choice A rationale

Chronic inflammation causes cellular destruction and leakage of enzymes into the bloodstream. During acute exacerbations of chronic pancreatitis, serum amylase levels rise above the normal range of 23 to 85 U/L due to pancreatic ductal obstruction.

Choice B rationale

Fat necrosis leads to the release of free fatty acids, which bind with ionized calcium in a process called saponification. This results in hypocalcemia, where serum calcium levels fall below the normal 9.0 to 10.5 mg/dL.

Choice C rationale

Serum lipase is highly specific to the pancreas and increases during inflammatory episodes. Lipase levels remain elevated longer than amylase, exceeding the normal reference range of 0 to 160 U/L as pancreatic acinar cells undergo damage.

Choice D rationale

Chronic pancreatitis often leads to the destruction of insulin-producing beta cells in the islets of Langerhans. This typically results in secondary diabetes mellitus and hyperglycemia, rather than decreased serum glucose levels below the normal 70 to 99 mg/dL.

Choice E rationale

Hypocalcemia is the expected finding due to calcium binding in necrotic fat. Elevated serum calcium is not consistent with pancreatitis; in fact, hypercalcemia is sometimes a causative factor for pancreatitis rather than a clinical manifestation of the disease.

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The intensive care nurse is caring for a client with sepsis. Which interventions can the nurse delegate to the unlicensed assistive personnel? Select All that Apply.

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Naxlex Comprehensive Predictor Exams

The nurse suspects that a client has decorticate posturing. Which findings support the nurse's suspicion?

Correct Answer is A

Explanation

A client with chronic pancreatitis is being evaluated. Which findings are most consistent with this condition? Select all that apply.

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

Explanation

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The intensive care nurse is caring for a client with sepsis.
Which interventions can the nurse delegate to the unlicensed assistive personnel? Select All that Apply.