A nurse on a cardiac care unit oversees the care of diﬀerent client’s cardiac health problems. Which action can be most appropriately delegated to personnel (UAP/CNA) when a patrent is found unresponsive?

Obtaining arterial blood gases

Giving IV epinephrine

Initiating CPR

Intubating the patient

Answer and Explanation

The Correct Answer is C

CPR (Cardiopulmonary Resuscitation) is a life-saving procedure that is performed when a person's heart has stopped beating. It involves chest compressions and rescue breathing to restore the circulation of oxygenated blood to the brain and other vital organs. The timely initiation of CPR can significantly increase the chances of a patient's survival.

In a healthcare setting, UAPs/CNAs are often trained to provide basic life support, including initiating CPR, until a healthcare provider arrives. However, giving IV epinephrine, intubating the patient, and obtaining arterial blood gases are all advanced medical procedures that require specialized training and expertise. These actions should only be performed by trained healthcare providers, such as registered nurses, physicians, or respiratory therapists, and cannot be delegated to UAPs/CNAs.

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Correct Answer is C

Explanation

A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.

A. Perform respiratory assessment. B. Document hypoxemia. C. Check the placement of the pulse oximeter. D. Report pulse oximetry to the health care provider.

Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

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A nurse on a cardiac care unit oversees the care of diﬀerent client’s cardiac health problems. Which action can be most appropriately delegated to personnel (UAP/CNA) when a patrent is found unresponsive?

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Correct Answer is C

Explanation

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Correct Answer is A

Explanation

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