A nurse is caring for a patient who has chronic obstructive pulmonary disease (COPD) and is 2 days postoperative after a laparoscopic cholecystectomy.
Which intervention for airway management should the nurse delegate to the UAP?
Teaching the patient to use an incentive spirometer.
Instructing the patient to cough effectively.
Auscultating breath sounds every 4 hours.
Assisting the patient to sit up on the side of the bed.
The Correct Answer is D
Choice A rationale
Teaching the patient to use an incentive spirometer requires nursing assessment of technique, understanding of respiratory physiology, and evaluation of patient learning. These are complex tasks that fall within the scope of professional nursing practice and cannot be delegated to unlicensed assistive personnel (UAP).
Choice B rationale
Instructing the patient to cough effectively involves assessing the patient's ability to cough, understanding their respiratory status, and providing individualized guidance based on their condition. This requires clinical judgment and specialized knowledge, making it a professional nursing responsibility rather than a delegated UAP task.
Choice C rationale
Auscultating breath sounds is a skilled assessment technique that requires advanced knowledge of respiratory anatomy, physiology, and pathology to accurately identify normal and adventitious sounds. This is a critical component of nursing assessment and cannot be delegated to unlicensed assistive personnel (UAP).
Choice D rationale
Assisting the patient to sit up on the side of the bed is a task related to patient mobility and positioning, which falls within the scope of practice for unlicensed assistive personnel (UAP). The UAP can provide physical assistance, ensure patient safety during movement, and follow clear instructions regarding positioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fluid-filled vesicles on the chest are not characteristic of Koplik spots. Vesicular rashes are more commonly associated with conditions like varicella (chickenpox) or herpes zoster, where the viral replication leads to the formation of small, elevated, fluid-filled lesions on the skin surface.
Choice B rationale
Koplik spots are pathognomonic for measles, appearing as small, irregular, bright red spots with bluish-white centers on the buccal mucosa, typically opposite the molars. They represent necrotic epithelial cells in the buccal mucosa and are an early diagnostic sign, often appearing 2-3 days before the generalized rash.
Choice C rationale
Enlarged parotid glands are characteristic of mumps, a viral infection affecting the salivary glands, particularly the parotid glands. This condition leads to swelling and tenderness in the areas anterior to the ears and below the jawline, distinct from the oral lesions seen in measles.
Choice D rationale
A gray pseudomembrane covering the pharynx is a hallmark sign of diphtheria, a bacterial infection caused by *Corynebacterium diphtheriae*. This pseudomembrane is a tough, adherent lesion composed of fibrin, bacteria, and necrotic cells that can obstruct the airway, unrelated to measles.
Correct Answer is C
Explanation
Choice A rationale
Administrative law judges typically preside over hearings and issue decisions in cases involving administrative agencies, but they are not the primary entities responsible for enforcing the Nurse Practice Act itself. Their role is more adjudicatory within specific administrative disputes, not the initial enforcement body for professional licensure laws.
Choice B rationale
Government agencies for health, such as departments of health, may oversee various aspects of public health and healthcare facilities. However, the specific legal enforcement of nursing practice acts and professional licensure falls under the purview of a specialized regulatory body dedicated to nursing.
Choice C rationale
The State Board of Nursing is the governmental agency legally mandated to regulate the practice of nursing within its jurisdiction. This includes establishing educational requirements, issuing licenses, setting standards of practice, and enforcing the Nurse Practice Act through disciplinary actions.
Choice D rationale
The local judicial system, including courts, primarily interprets laws and resolves legal disputes. While they may be involved in appeals of Board of Nursing decisions or criminal cases related to nursing misconduct, they are not the direct enforcement body for the Nurse Practice Act.
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