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 D
Explanation
Choice A rationale
Applying wrist and leg restraints significantly restricts a client's movement and can exacerbate confusion and agitation, potentially leading to increased injury risk and psychological distress. This intervention can also impair circulation and skin integrity if not meticulously monitored, and should only be used as a last resort when less restrictive measures have failed. Normal physiological response to restraint includes increased anxiety.
Choice B rationale
Administering medication to sedate a client might reduce restlessness temporarily but could also deepen confusion, increase the risk of falls, and mask underlying medical issues causing the change in mental status. Pharmacological interventions should be carefully considered, with the lowest effective dose, and after a thorough assessment of the cause of the altered mental state. Normal sedation levels aim for calm without excessive drowsiness.
Choice C rationale
While involving family can be supportive, expecting them to stay with the client constantly in a hospital setting may not always be feasible or sustainable. Although family presence can provide comfort and reorientation, it does not directly address the immediate environmental safety needs of a confused and restless client in a hospital. Normal family roles are supportive.
Choice D rationale
Moving the client to a room closer to the nurses' station allows for more frequent and direct observation by nursing staff. This increased proximity enables prompt intervention if the client attempts to get out of bed, falls, or exhibits further changes in mental status, enhancing safety without resorting to restrictive measures. Normal nursing practice prioritizes close monitoring for at-risk clients.
Correct Answer is ["0.25"]
Explanation
Step 1 is to convert the child's weight from pounds to kilograms:. 13.2 lbs ÷ 2.2 lbs/kg = 6 kg.
Step 2 is to calculate the ordered dose in mg:. 25 mcg = 0.025 mg.
Step 3 is to calculate the volume to be drawn up for a single dose:. 0.025 mg ÷ (0.1 mg/mL) = 0.25 mL.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.