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 B
Explanation
A. Weight gain is more commonly associated with right-sided heart failure due to fluid retention and peripheral edema, not left-sided heart failure.
B. Shortness of breath (dyspnea) is correct. Left-sided heart failure causes pulmonary congestion, leading to dyspnea, orthopnea, and pulmonary edema as blood backs up into the lungs.
C. Pulmonary embolism is not a direct manifestation of left-sided heart failure. While heart failure increases the risk of clot formation, a pulmonary embolism is a separate condition.
D. Anorexia is more common in right-sided heart failure, as systemic venous congestion can lead to gastrointestinal edema and poor appetite.
Correct Answer is D
Explanation
A. Intermittent claudication with pallor is typically associated with peripheral artery disease (PAD) rather than myocardial infarction.
B. Jugular vein distention and dependent edema are signs of right-sided heart failure, which may develop after an MI but are not classic acute MI symptoms.
C. Mid-epigastric pain and heartburn can sometimes be confused with MI symptoms, but heartburn alone is not diagnostic of an MI.
D. Diaphoresis and cool clammy skin are correct. These symptoms occur due to sympathetic nervous system activation in response to cardiac ischemia, leading to vasoconstriction, sweating, and signs of impending shock.
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