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 B
Explanation
Gentamicin is an antibiotic that is usually administered via IV infusion. The peak level is the highest concentration of the medication in the bloodstream, and it is important to monitor it to ensure therapeutic levels are achieved without reaching toxic levels.
Drawing the peak level 30 minutes after the infusion is complete allows enough time for the medication to distribute throughout the body and reach its peak concentration. This timing provides an accurate representation of the highest drug concentration in the bloodstream. 30 minutes before starting the infusion: Drawing the peak level before starting the infusion would not accurately reflect the peak concentration of the medication in the bloodstream. Immediately before the next dose of Gentamicin: Drawing the peak level immediately before the next dose would not provide an accurate assessment of the highest drug concentration, as the levels would have started to decrease due to elimination.
1 hour after infusion is complete: Waiting for 1 hour after the infusion is complete may result in missing the actual peak concentration of the medication in the bloodstream, as it may have already started to decline.
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 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.
The arterial blood gas results do not indicate any compensation. Compensation occurs when the body attempts to restore the pH balance by adjusting the respiratory or metabolic systems. In this case, there is no compensation observed because the PaCO2 level is within the normal range and not significantly altered.
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