The nurse and unlicensed assistive personnel (UAP) are caring for an elderly client diagnosed with emphysema. Which nursing tasks could be delegated to the UAP to improve gas exchange? (Select All that Apply)
Assess level of consciousness
Auscultate breath sounds
Encourage deep breathing exercises
Record pulse oximeter reading
Keep the head of bed elevated
Correct Answer : C,D,E
A. Assessing level of consciousness is a nursing responsibility and cannot be delegated to the UAP.
B. Auscultating breath sounds requires clinical judgment and must be performed by a nurse.
C. Encouraging deep breathing exercises is within the scope of a UAP and can help improve gas exchange.
D. Recording a pulse oximeter reading is a task that can be delegated to a UAP, though interpretation remains the nurse’s responsibility.
E. Keeping the head of the bed elevated helps improve oxygenation and can be done by the UAP.
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Related Questions
Correct Answer is D
Explanation
A. Hemoptysis (coughing up blood) is a known symptom of a pulmonary embolism (PE). It results from lung tissue damage due to obstructed blood flow.
B. Petechiae are not typically associated with a PE. They are more commonly linked to conditions such as thrombocytopenia or fat embolism syndrome.
C. Tachycardia is a common manifestation of a PE. The heart rate increases as a compensatory mechanism due to decreased oxygenation.
D. Facial weakness is not a typical sign of PE. It is more commonly associated with conditions like stroke or Bell's palsy.
Correct Answer is ["1636.4"]
Explanation
- Convert pounds to kilograms:
- Weight in kilograms = 90 pounds / 2.2 pounds/kg = 40.9090... kg. For practical purposes, we can round to 40.91kg.
- Calculate the heparin dose:
- The ordered bolus dose is 40 units/kg.
- Heparin dose = 40.91 kg 40 units/kg = 1636.4 units.
- Round to the nearest tenth:
- The heparin dose is 1636.4 units.
= 1636.4 units
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