Which intervention for VTE care and prevention can the RN delegate to the nursing assistant?

Evaluate the effect of anticoagulant drugs by monitoring appropriate laboratory results and side effects of therapy

Help ambulatory patients to walk at least 4 to 6 times daily.

Teach patients at risk for VTE about preventive measures

Assess patients for VTE risk and monitor for VTE in at-risk patients

Answer and Explanation

The Correct Answer is B

Choice A reason: Evaluating anticoagulants requires interpreting labs like PT/INR and assessing bleeding, a skilled nursing task. Delegation to an assistant is inappropriate, as it demands clinical judgment beyond their scope, involving pharmacokinetics and patient safety monitoring.

Choice B reason: Assisting ambulation promotes venous return, reducing VTE risk via muscle pump action on veins. This physical task aligns with a nursing assistant’s scope, requiring no clinical analysis, making it a safe, effective delegation for prevention.

Choice C reason: Teaching about VTE prevention involves explaining risks and interventions, requiring nursing knowledge of pathophysiology. Assistants lack training for patient education, so this remains an RN duty to ensure accuracy and comprehension.

Choice D reason: Assessing VTE risk and monitoring involve clinical skills like inspecting for swelling or interpreting symptoms. This exceeds an assistant’s scope, as it requires diagnostic reasoning and expertise reserved for licensed nurses.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: CF-related diabetes (CFRD) from pancreatic damage requires insulin, as glucose of 180-250 mg/dL indicates insulin deficiency. Teaching administration addresses this directly, aligning with standard CFRD management for glycemic control.

Choice B reason: Oral hypoglycemics aren’t effective in CFRD, which stems from insulin lack, not resistance. Glucose levels of 180-250 mg/dL need insulin, making this inappropriate for CF’s unique endocrine pathology.

Choice C reason: Diet impacts glucose, but CFRD requires insulin first, not just dietary control. Levels of 180-250 mg/dL exceed dietary management alone, so this is secondary to initiating insulin therapy in CF.

Choice D reason: Pancreatic enzymes aid digestion in CF, not glucose control directly. Evaluating use is routine, but hyperglycemia of 180-250 mg/dL points to CFRD, necessitating insulin over enzyme adjustment.

A. Mantoux testing shows an induration of 10 mm. B. TB medications have been taken for 6 months. C. Sputum smears for acid-fast bacilli are negative. D. Chest x-ray shows no upper lobe infiltrates.

Correct Answer is C

Explanation

Choice A reason: Mantoux induration of 10 mm indicates TB exposure, not active infection status. It’s a diagnostic tool, not a marker for contagiousness, so it doesn’t guide discontinuation of airborne precautions in treatment.

Choice B reason: Six months of TB meds suggests treatment progress, but contagiousness persists until sputum clears. Duration alone isn’t enough; microbiologic evidence is required to lift precautions, per infection control standards.

Choice C reason: Negative sputum smears for acid-fast bacilli (three consecutive) confirm non-infectiousness in TB. This microbiological clearance allows discontinuation of airborne precautions, as the patient no longer spreads viable bacteria via droplets.

Choice D reason: Clear x-ray (no infiltrates) shows healing, but sputum can remain infectious. Radiologic improvement lags behind contagiousness, so negative smears, not imaging, determine when precautions can safely end.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which intervention for VTE care and prevention can the RN delegate to the nursing assistant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with cystic fibrosis has blood glucose levels that are consistently between 180 to 250 mg/dL. Which action will the nurse expect to implement?

Correct Answer is A

Explanation

A patient is hospitalized with active tuberculosis (TB). Which assessment finding indicates to the nurse that prescribed airborne precautions are likely to be discontinued?

Correct Answer is C

Explanation

In a severely anemic patient, which assessment findings would the nurse expect to find?

The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

Complete the following sentence: Given the patient’s elevated blood pressure and inconsistent medication adherence, the nurse should prioritize (intervention) to help improve blood pressure control and patient outcome

Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Based on Maria’s presenting symptoms and diagnostic test, the nurse suspects the patient will be diagnosed with ___________.

After change-of-shift report, which patient would the nurse assess first?

Based on the patient’s medication list, which of the following medications directly treat hypertension? (Select all that apply)

A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?