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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Crossing the legs can actually increase the risk of venous stasis and clot formation, which can lead to a pulmonary embolism. The client needs further teaching to avoid this habit.
B. Smoking increases the risk of blood clot formation, so quitting smoking is an appropriate preventive measure.
C. Staying hydrated helps maintain good blood flow and reduces the risk of clot formation.
D. Regular exercise and weight management help prevent venous stasis and clot formation, lowering the risk of pulmonary embolism.
Correct Answer is A
Explanation
A. Pleural effusion is a common complication of heart failure. Increased pressure in the pulmonary circulation can cause fluid to accumulate in the pleural space, leading to dyspnea and decreased lung expansion.
B. Infection is not a direct complication of heart failure. However, individuals with heart failure may have an increased risk of infections due to a weakened immune system.
C. Asthma is not a complication of heart failure. While both conditions can cause shortness of breath, asthma is a separate respiratory disorder.
D. Hemorrhage is not associated with heart failure. Instead, heart failure can lead to clotting abnormalities or increased bleeding risk if the client is on anticoagulants.
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