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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Acetaminophen reduces fever, but 101.2°F isn’t critical in sepsis, where hypotension (90/56 mmHg) signals shock. Addressing fever alone ignores systemic instability, delaying urgent intervention for a deteriorating patient needing comprehensive management.
Choice B reason: Hypotension (90/56 mmHg) and tachypnea (34 breaths/min) indicate septic shock, requiring immediate escalation. Notifying the provider ensures rapid fluid resuscitation and vasopressors, critical in gram-negative sepsis to reverse hypoperfusion and prevent organ failure.
Choice C reason: Pulse oximetry assesses oxygenation, useful in sepsis with tachypnea. However, hypotension is more immediately life-threatening, prioritizing provider notification for systemic treatment over a single parameter check that delays broader stabilization efforts.
Choice D reason: IV antibiotics target sepsis’s cause, but a scheduled dose doesn’t address acute hypotension urgency. Provider notification supersedes routine administration, as shock requires fluids and pressors now, not just infection control, to save the patient.
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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