Nokea
The nurse and an 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.
- A. Keep the head of the bed elevated.
- B. Encourage deep breathing exercises.
- C. Record pulse oximeter reading.
- D. Assess level of consciousness.
- E. Auscultate breath sounds.
Correct Answer: A,C
Rationale: UAPs can keep the head of the bed elevated (1) to improve lung expansion and record pulse oximetry (3), a non-invasive task. Encouraging deep breathing (2) requires teaching, a nursing role. Assessing consciousness (4) and auscultating breath sounds (5) are assessment tasks reserved for nurses.
You may also like to solve these questions
Which nursing action is essential during tracheal suctioning?
- A. Using a lubricant such as petroleum jelly
- B. Administering 100% oxygen before and after suctioning
- C. Making sure the suction catheter is open or on during insertion
- D. Assisting the client to assume a supine position during suctioning
Correct Answer: B
Rationale: Administering 100% oxygen before and after suctioning prevents hypoxia during the procedure.
Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy?
- A. I must avoid hair spray and powders.
- B. I should take a shower instead of a tub bath.
- C. I will need to cleanse around the stoma daily.
- D. I can use an electric larynx to speak.
Correct Answer: D
Rationale: Using an electric larynx (D) is related to speech, not tracheostomy care, indicating a misunderstanding of tracheostomy management. Avoiding hair spray/powders (A), showering (B), and daily stoma cleaning (C) are correct tracheostomy care practices.
Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?
- A. Airborne isolation.
- B. Droplet isolation.
- C. Reverse isolation.
- D. Strict isolation.
Correct Answer: A
Rationale: SARS is transmitted via respiratory droplets and possibly aerosols, requiring airborne isolation (A) with a negative pressure room and N95 masks. Droplet isolation (B) is insufficient for potential aerosol transmission. Reverse isolation (C) protects immunocompromised patients, not applicable here. Strict isolation (D) is not a standard term for SARS precautions.
You assist your patient with using their inhaler. The inhaler contains the medication Budesonide. Before administering the inhaler, you will want to connect what device to the inhaler to help decrease the patient from developing?
- A. Peak flow meter; pneumonia
- B. Incentive spirometer; thrush
- C. Spacer; thrush
- D. Peak flow meter; mouth sores
Correct Answer: C
Rationale: A spacer helps deliver Budesonide, an inhaled corticosteroid, more effectively to the lungs, reducing the risk of oral thrush by minimizing medication deposition in the mouth.
Which statement by the client indicates an accurate understanding of the purpose of aerosol therapy?
- A. Aerosol therapy relieves tissue irritation.
- B. Aerosol therapy delivers medication directly to the lungs.
- C. Aerosolization dries respiratory passages.
- D. Aerosol therapy helps to slow breathing.
Correct Answer: B
Rationale: Aerosol therapy delivers medication directly to the lungs, targeting the respiratory tract for effective treatment of bronchitis.