The nurse and unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? (Select All that Apply)
Assess level of consciousness
Auscultate breath sounds
Encourage deep breathing exercises
Record pulse oximeter reading
Keep the head of bed elevated
Correct Answer : C,D,E
A. Assessing level of consciousness is a nursing responsibility and cannot be delegated to the UAP.
B. Auscultating breath sounds requires clinical judgment and must be performed by a nurse.
C. Encouraging deep breathing exercises is within the scope of a UAP and can help improve gas exchange.
D. Recording a pulse oximeter reading is a task that can be delegated to a UAP, though interpretation remains the nurse’s responsibility.
E. Keeping the head of the bed elevated helps improve oxygenation and can be done by the UAP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Vital signs . The client has tachycardia (HR 138/min) and tachypnea (RR 28/min), which may indicate worsening heart failure or fluid overload. The low blood pressure (96/75 mmHg) is also concerning, especially with rapid ventricular response (RVR).
B. Respiratory assessment . The presence of a frequent cough with pink-tinged sputum suggests pulmonary congestion or pulmonary edema, a sign of worsening left-sided heart failure.
C. Renal function . The BUN of 28 mg/dL (elevated) and creatinine of 1.5 mg/dL (borderline high) suggest possible kidney impairment due to decreased cardiac output and poor perfusion.
D. Cardiac enzymes . The client denies chest pain or discomfort, so cardiac enzymes are not the immediate priority.
E. BNP (B-type natriuretic peptide) . BNP is a key marker of heart failure severity and helps guide treatment decisions.
F. ECG results . The atrial fibrillation with RVR increases the risk of hemodynamic instability and potential thromboembolic events, requiring urgent intervention.
G. Neurologic status . The client is alert, oriented, and following commands, so no immediate neurologic concerns are present.
Correct Answer is A
Explanation
A. Weight loss is not a common side effect of prednisone. Instead, weight gain due to fluid retention and increased appetite is a frequent side effect.
B. Dry mouth can occur with prednisone use, though it is not the most common side effect.
C. Hyperglycemia is a well-known side effect because corticosteroids increase glucose production and reduce insulin sensitivity.
D. Decreased wound healing is a common effect due to prednisone's immunosuppressive and anti-inflammatory properties, which impair tissue repair.
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