When providing skin care to an older adult client, the nurse should include what interventions to protect the client's skin? Select all that apply.

Choice A rationale

Delegation requires the nurse to provide an appropriate level of supervision regardless of the delegatee's perceived experience level. Professional nursing standards dictate that the delegating nurse must monitor the performance of the task to ensure it is completed safely. Assuming that an experienced delegate requires no oversight is a breach of safety protocols and professional responsibility. Continuous evaluation is necessary to maintain high quality care and to intervene if the clinical situation changes unexpectedly.

Choice B rationale

While the nurse transfers the authority to perform a specific task to a competent individual, they do not transfer professional accountability. The delegate becomes responsible for the actual performance of the action, but the registered nurse remains legally and professionally liable for the decision to delegate. Accountability involves being answerable for the outcomes of the nursing care provided. This distinction is vital in maintaining the integrity of nursing practice and ensuring patient safety remains the priority.

Choice C rationale

This statement is incorrect because delegation does not absolve the nurse of their professional duties. The nurse must continue to assess the patient, evaluate the effectiveness of the delegated task, and ensure the task was performed correctly. If a nurse believes they are no longer responsible, it creates a gap in the continuity of care and increases the risk of adverse events. Ongoing engagement with the delegate and the patient is required until the care is complete.

Choice D rationale

Accountability is the hallmark of professional nursing practice during the delegation process. The nurse uses clinical judgment to determine which tasks are appropriate for delegation based on the complexity of the patient's needs and the competency of the staff. Even after the task is assigned, the nurse must ensure the outcome meets the standard of care. This involves reviewing results, providing feedback, and documenting the final result of the delegated action in the medical record.

Choice A rationale

Bronchial lung sounds are normal, high-pitched, loud sounds heard over the trachea and larynx. They are characterized by a short inspiratory phase and a long expiratory phase. While hearing these sounds in the peripheral lung fields might indicate an abnormality like consolidation, the term itself refers to a specific type of breath sound rather than the structural pathology of lung collapse or the incomplete expansion of the alveolar units within the pulmonary system.

Choice B rationale

Surfactant is a lipoprotein complex produced by Type II alveolar cells that reduces surface tension at the air-liquid interface within the alveoli. Its primary function is to prevent the lungs from collapsing during expiration by making it easier for the alveoli to expand during inhalation. While a deficiency in surfactant can lead to lung collapse, the surfactant itself is a substance, not the clinical condition of collapsed or unexpanded lung tissue described in the question.

Choice C rationale

Bradypnea is a clinical sign defined as an abnormally slow respiratory rate, typically fewer than 12 breaths per minute in an adult. This condition can be caused by various factors, including drug overdose, metabolic derangements, or increased intracranial pressure. While a slow respiratory rate can lead to poor lung expansion over time, it is a measurement of breathing frequency and does not describe the anatomical state of the lung tissue or alveolar collapse.

Choice D rationale

Atelectasis is the medical term for the partial or complete collapse of a lung or a lobe of a lung, occurring when the alveoli become deflated or filled with alveolar fluid. It is common after surgery or in patients who are bedridden and cannot breathe deeply. This condition reduces the surface area available for gas exchange, potentially leading to hypoxemia. Management often includes deep breathing exercises, coughing, and the use of incentive spirometry to re-expand the lung tissue.