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?

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.

Choice A rationale

While hearing loss can occur in some individuals with spina bifida due to associated anomalies or complications like meningitis, it is not as universally expected as other neurological impairments. The primary impact of hydrocephalus and neurological damage often manifests in areas directly related to brain development and function, making hearing loss a less common direct consequence.

Choice B rationale

Neurological damage associated with hydrocephalus and spina bifida frequently affects brain regions responsible for speech production and language processing. This can lead to various speech problems, including dysarthria or apraxia of speech, due to impaired motor control or cognitive deficits impacting linguistic expression and comprehension.

Choice C rationale

Frequent seizures are a potential complication of hydrocephalus and neurological damage due to abnormal electrical activity in the brain caused by structural anomalies or increased intracranial pressure. However, while possible, they are not as universally present in all cases as other common motor and cognitive impairments, making them a less frequent expectation.

Choice D rationale

Spina bifida often involves malformations of the spinal cord, directly impacting nerve function to the lower extremities. Hydrocephalus, by causing increased intracranial pressure and brain damage, can further impair motor control pathways. This combination frequently leads to motor deficits, resulting in varying degrees of difficulty walking or complete paralysis.

Choice E rationale

Hydrocephalus, especially when associated with neurological damage, can significantly impair cognitive development due to increased intracranial pressure and damage to brain tissue. This can manifest as delays in various cognitive domains, including learning, memory, problem-solving, and executive functions, impacting overall intellectual functioning.