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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Auscultating lung sounds post-albuterol assesses treatment efficacy in asthma exacerbation. Reduced wheezing or improved air entry indicates bronchodilation, guiding further care, making it the priority to evaluate respiratory response immediately.
Choice B reason: Measuring temperature monitors infection, a possible asthma trigger, but it’s not the priority post-treatment. Albuterol targets acute bronchospasm, so assessing respiratory effect trumps systemic checks like fever in this moment.
Choice C reason: Encouraging ambulation is premature post-albuterol; patients need rest during exacerbation. It risks worsening dyspnea before confirming treatment success, making it less urgent than evaluating lung response to the bronchodilator.
Choice D reason: Documentation is essential but secondary to patient assessment post-treatment. Auscultating lung sounds first ensures albuterol’s effect is evaluated, as clinical response guides care before recording in the record.
Correct Answer is B
Explanation
Choice A reason: Beta blockers like metoprolol reduce heart rate and demand, improving heart failure long-term. They don’t directly reduce fluid overload causing dyspnea and fatigue, focusing instead on cardiac remodeling, not acute volume relief.
Choice B reason: Diuretics like furosemide increase urine output, reducing fluid overload in heart failure. They directly relieve dyspnea and fatigue by lowering preload and pulmonary congestion, the most effective class for these symptoms.
Choice C reason: ACE inhibitors like lisinopril ease vascular resistance, aiding heart failure. They reduce fluid indirectly via aldosterone suppression, but diuretics act faster on acute overload, making them secondary for immediate symptom relief.
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