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?

Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg.

Set up the automatic noninvasive BP machine to take readings every 15 minutes.

Teach the patient stress-relieving techniques.

Evaluate effectiveness of nitroprusside therapy on blood pressure (BP).

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Bradypnea (slow breathing) isn’t typical in asthma exacerbation; tachypnea occurs due to airway obstruction. Reduced respiratory rate suggests fatigue or resolution, not active exacerbation, contradicting the physiology of acute bronchoconstriction.

Choice B reason: Wheezing results from turbulent airflow through narrowed bronchioles in asthma exacerbation. It’s a hallmark sign, reflecting reversible obstruction from inflammation and bronchospasm, consistently present during acute episodes requiring intervention.

Choice C reason: Bradycardia isn’t associated with asthma exacerbation; tachycardia is common from hypoxia and stress. Slow heart rate may indicate severe hypoxia late-stage, but it’s not a typical finding in active exacerbation.

Choice D reason: Accessory muscle use (e.g., sternocleidomastoid) compensates for obstructed airflow in asthma exacerbation. It reflects increased work of breathing due to bronchoconstriction, a frequent physical sign during acute respiratory distress.

Choice E reason: Decreased oxygen saturation occurs in asthma exacerbation from ventilation-perfusion mismatch. Inflamed airways limit oxygen delivery, dropping SpO2 below 95%, a common finding necessitating bronchodilators and oxygen therapy.

A. Encouraging the patient to ambulate as much as tolerated B. Evaluating the effectiveness of opioid analgesics C. Teaching the patient about high-protein, high-calorie foods D. Limiting the patient’s intake of oral and IV fluids

Correct Answer is B

Explanation

Choice A reason: Ambulation in sickle cell crisis risks worsening pain and ischemia from exertion. Rest preserves oxygen, as sickle hemoglobin clogs vessels; encouraging movement contradicts physiology, delaying recovery in acute vaso-occlusion.

Choice B reason: Opioids relieve severe pain in sickle cell crisis from vaso-occlusion. Evaluating their effect ensures adequate control, as pain signals ongoing tissue hypoxia, guiding dose adjustments for comfort and healing.

Choice C reason: High-protein, high-calorie diets support chronic sickle cell needs, not acute crisis. Teaching this now is secondary, as pain and hydration take priority over nutrition education during active vaso-occlusive events.

Choice D reason: Limiting fluids worsens sickle cell crisis by increasing blood viscosity, promoting sickling. Hydration (IV/oral) dilutes hemoglobin S, improving flow, so restriction contradicts evidence-based crisis management principles.

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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?

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