The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?
Teach the patient to pursed lip breath.
Auscultate breath sounds every 4 hours.
Assist the patient to get out of bed.
Plan patient activities to minimize exertion.
The Correct Answer is C
Assisting the patient to get out of bed is a task that can be safely delegated to UAP, as long as the patient's mobility and transfer status allow for assistance without the need for specialized nursing skills. UAPs are trained to provide basic patient care, including assisting with activities of daily living, under the supervision and direction of licensed healthcare professionals.
Teaching the patient to purse lip breath requires knowledge and understanding of the technique, as well as the ability to assess the patient's response and provide feedback. This is best done by a licensed healthcare professional, such as a nurse or respiratory therapist. Auscultating breath sounds every 4 hours requires the ability to correctly use a stethoscope and interpret the findings. This task falls within the scope of practice of a nurse or respiratory therapist who has received appropriate training.
Planning patient activities to minimize exertion requires knowledge of the patient's condition, limitations, and goals. It involves assessment, evaluation, and coordination of care, which are typically performed by licensed healthcare professionals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.
In this case, the primary disturbance is metabolic alkalosis, which is likely caused by the persistent vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.
Since there is no significant deviation from the normal range in the PaCO2 level, the respiratory system has not effectively compensated for the metabolic alkalosis. Therefore, it is considered uncompensated.
Correct Answer is D
Explanation
The client's complaint of hemoptysis (coughing up blood) and a positive Mantoux test (4 cm induration) suggest the possibility of tuberculosis (TB) infection. TB is an airborne infectious disease, and placing the client in airborne isolation is necessary to prevent the spread of the infection to others.
Antibiotics may be used to treat tuberculosis, but the initial step would be to isolate the client and confirm the diagnosis before starting specific treatment.
A CT scan may be ordered to further evaluate the client's condition, but it is not the immediate action required in this case. Isolation and confirmation of the diagnosis take priority. While the client may require oxygen therapy based on their respiratory symptoms, it is not the primary action to take at this stage. Isolation and further evaluation are necessary before initiating specific treatments.
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