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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acute neurological deficits following a stroke increase the risk of secondary complications. Knowledge of cranial nerve involvement and protective reflexes is vital. The nurse must prioritize airway and respiratory safety within the critical 24 hour post ischemic event window.
Choice A rationale
Right sided weakness often includes the facial and pharyngeal muscles, impairing the gag reflex and swallowing. This increases the risk of food or secretions entering the lungs, leading to pneumonia or acute respiratory distress during recovery.
Choice B rationale
While urinary retention can occur after a stroke due to neurogenic bladder or immobility, it is not an immediate life threat. It requires monitoring and management but takes lower priority than ensuring the client maintains a patent airway.
Choice C rationale
Contractures are a long term complication of immobility and muscle spasticity following a stroke. While range of motion exercises are important for rehabilitation, they are not a priority during the first 24 hours of acute stabilization.
Choice D rationale
Depression is a common psychological consequence of the lifestyle changes and deficits caused by a stroke. However, psychological assessment occurs later in the care plan after the client is physiologically stable and out of danger.
Correct Answer is D
Explanation
Managing acute decompensated heart failure requires understanding perfusion pressure and cardiovascular hemodynamics. Knowledge of mean arterial pressure and vasopressor pharmacology is necessary. The priority is maintaining vital organ perfusion when the MAP falls below critical thresholds required for cellular oxygenation.
Choice A rationale
Fluid boluses can exacerbate pulmonary edema in acute decompensated heart failure. While MAP is low, adding volume increases preload, which a failing left ventricle cannot pump, leading to further respiratory distress and worsening of the cardiac crisis.
Choice B rationale
Intubation addresses respiratory failure and oxygenation but does not directly correct the primary hemodynamic issue of low perfusion pressure. While it may become necessary, the immediate priority is restoring MAP to ensure coronary and renal perfusion.
Choice C rationale
High Fowler's position assists with oxygenation by reducing venous return and decreasing pulmonary congestion. However, in the presence of a dangerously low MAP of 55 mm Hg, this position may further decrease cerebral and systemic perfusion.
Choice D rationale
A MAP below 60 to 65 mm Hg indicates inadequate organ perfusion. Norepinephrine provides potent vasoconstriction and minimal inotropy, raising systemic vascular resistance to increase the MAP quickly, thereby protecting the brain, heart, and kidneys from ischemia..
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