A long-term-care resident with venous stasis ulcers is treated with Unna's boot. Which of the nursing activities included in the resident's care is best for you to delegate to a nursing assistant?

Correct Answer: D

Rationale: The correct answer, option D, "Assist patient with cleaning around Unna's boot," is best delegated to a nursing assistant because it involves a task that is focused on direct patient care and maintenance rather than assessment or education. Cleaning around the Unna's boot is a practical task that can be safely performed by a nursing assistant under the supervision and direction of a registered nurse. Option A, "Monitor capillary perfusion once every 8 hours," involves an assessment task that requires a higher level of clinical judgment and skill, making it more appropriate for a registered nurse to perform. Assessing capillary perfusion is crucial in evaluating the effectiveness of the treatment and detecting any complications that may arise. Option B, "Teach family members the signs of infection," requires specialized knowledge and communication skills to effectively educate others on a medical topic. This task should be handled by a healthcare professional, such as a registered nurse, who can provide accurate information and address any questions or concerns from family members. Option C, "Evaluate foot sensation and movement each shift," involves ongoing patient assessment that requires clinical knowledge to interpret findings accurately. Nursing assistants may assist with mobility and activities of daily living but may not have the training to perform detailed sensory and motor assessments. In an educational context, understanding delegation in nursing is essential for providing safe and efficient patient care. Nurses need to delegate tasks appropriately based on the complexity of the task, the competency of the team member, and the patient's condition. By delegating tasks effectively, nurses can optimize workflow, enhance patient outcomes, and promote teamwork among healthcare providers.

Correct Answer: C

Rationale: The correct answer is C) The INR must be maintained between 2.5 and 3.5 for anticoagulant monitoring. Explanation: When a client has a mechanical valve placed, they require anticoagulation therapy to prevent blood clots. The International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy. For patients with a mechanical valve, the target INR range is higher (2.5-3.5) compared to other conditions to ensure adequate anticoagulation without increasing the risk of bleeding. Why the other options are wrong: A) The PT must remain below 1.5 times the control value - This statement does not accurately reflect the monitoring requirements for anticoagulation in patients with mechanical valves. B) The PTT must be higher than 2.5 times the control value - Partial Thromboplastin Time (PTT) is not the primary test used to monitor anticoagulation in patients with mechanical valves. D) The INR must be maintained below 2.5 for anticoagulant monitoring - This range is too low for patients with mechanical valves and may increase the risk of thrombosis. Educational context: Understanding the specific monitoring requirements for anticoagulation in patients with mechanical valves is crucial for nurses caring for these clients. Proper anticoagulation management can help prevent complications such as thromboembolism or bleeding. Nurses need to educate clients on the importance of regular INR monitoring, adherence to medication regimens, dietary considerations, and signs of potential complications.

Correct Answer: C

Rationale: In this case, the correct answer is C) Supraventricular Tachycardia (SVT). SVT is characterized by a heart rate greater than 150 beats per minute, shortened diastole, and inadequate time for the heart to fill properly. This rapid rhythm originates above the ventricles and can lead to symptoms such as palpitations, chest pain, dizziness, and even syncope. Sinus bradycardia (option A) is a slow heart rhythm, not consistent with the scenario described in the question. Sinus tachycardia (option B) is a fast heart rhythm, but diastole is not shortened in this rhythm. Atrial flutter (option D) is a specific type of supraventricular arrhythmia, but it typically presents with a sawtooth pattern on ECG, which is not mentioned in the question stem. Understanding different cardiac rhythms is crucial for nurses working in telemetry units or any healthcare setting where cardiac monitoring is performed. Recognizing these rhythms promptly is essential for initiating appropriate interventions and preventing potential complications for the patient. Nurses must be adept at interpreting telemetry alarms accurately to provide timely and effective care.

Correct Answer: A

Rationale: In right-sided heart failure, the correct symptom observed is dependent pitting edema (Option A). This occurs due to fluid retention and increased venous pressure, leading to swelling in the lower extremities. Exertional dyspnea (Option B) is more commonly associated with left-sided heart failure, where there is a buildup of fluid in the lungs causing difficulty breathing during activity. Orthopnea (Option C) is also a symptom of left-sided heart failure, characterized by difficulty breathing when lying flat. Hemoptysis (Option D) is the coughing up of blood and is not typically associated with heart failure but can be a sign of other serious conditions such as pulmonary embolism or pneumonia. Educationally, understanding the distinct symptoms of left-sided versus right-sided heart failure is crucial for accurate assessment and management of patients with cardiovascular conditions. Recognizing these symptoms helps healthcare professionals provide appropriate interventions and improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) One or more arteries that supply blood to his heart are blocked, thereby preventing an adequate amount of blood from getting to his cardiac muscles. This response is the most appropriate because it directly addresses the patient's condition of myocardial infarction (heart attack). It provides a clear and accurate explanation in simple terms, helping the patient understand the cause of his symptoms. Option A is incorrect because leaving the patient uninformed can increase anxiety and hinder patient-provider communication. It is important to provide basic information to the patient to alleviate fear and facilitate understanding. Option B is incorrect as it refers to a congenital heart condition related to the aortic valve, which is not relevant to the patient's current situation of myocardial infarction. Option C is incorrect and promotes a harmful stereotype that overweight individuals are destined to have a heart attack. This statement lacks medical accuracy and can contribute to patient stigma. Educational context: In healthcare, effective communication with patients is essential for building trust, ensuring informed decision-making, and promoting patient satisfaction. Providing clear and accurate information empowers patients to participate in their care and promotes better health outcomes. Educating patients about their condition in simple language helps them understand the importance of treatment and lifestyle modifications.