A nurse is caring for a client who presents with chronic obstructive pulmonary disorder (COPD), Which of the following task can the nurse delegate to the UAP?
Administer albuterol via inhalation device to the client.
performing initial respiratory assessment to determine baseline respiratory rate.
Assist the client with oral hygiene following inhaled corticosteroid administration by the nurse.
Assess the client's lung sounds to determine if wheezing is present.
The Correct Answer is C
A) Administer albuterol via inhalation device to the client: This task cannot be delegated to the unlicensed assistive personnel (UAP). Administering medications, especially inhaled bronchodilators like albuterol, requires a licensed nurse to ensure proper technique, monitor the client for adverse effects, and assess the effectiveness of the treatment.
B) Performing initial respiratory assessment to determine baseline respiratory rate: This task also cannot be delegated to the UAP. Assessing respiratory status, including determining baseline respiratory rate and identifying any abnormalities, requires critical thinking and clinical judgment that a nurse must perform.
C) Assist the client with oral hygiene following inhaled corticosteroid administration by the nurse: This task can be delegated to the UAP. Assisting with oral hygiene is within the scope of practice for UAPs, and it is essential after administering inhaled corticosteroids to help prevent oral thrush and maintain oral health.
D) Assess the client's lung sounds to determine if wheezing is present: This task cannot be delegated to the UAP. Assessing lung sounds is a critical nursing assessment that requires the knowledge and skills of a licensed nurse to interpret findings and make clinical decisions based on the assessment.
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Correct Answer is C
Explanation
A) Palpitations: While palpitations can be concerning for many medications, they are not a commonly reported side effect of dextromethorphan. This medication primarily acts as a cough suppressant and does not typically have cardiovascular effects that would lead to palpitations. Therefore, clients should not primarily monitor for this side effect when taking dextromethorphan.
B) Hypertension: Dextromethorphan is not generally associated with causing hypertension. Its main action is to suppress the cough reflex, and it does not typically influence blood pressure levels. Patients taking this medication should focus on other side effects rather than worrying about hypertension.
C) Ataxia: Ataxia, or impaired coordination, is a notable adverse effect associated with dextromethorphan, especially at higher doses or when combined with other central nervous system depressants like alcohol. This side effect can lead to dizziness and increased risk of falls or accidents, making it important for clients to be aware of their coordination and alertness levels while on this medication. Advising patients to avoid driving or operating heavy machinery if they experience ataxia is essential for their safety.
D) Diarrhea: Diarrhea is not a common adverse effect of dextromethorphan. The medication is primarily used for its antitussive properties, and gastrointestinal disturbances like diarrhea are generally not associated with its use. If patients experience gastrointestinal symptoms while taking this medication, they may need to consider other factors or medications that could be contributing to those symptoms.
Correct Answer is A
Explanation
A) Beta-Blockers: The use of beta-blockers is a direct contraindication to albuterol administration. Albuterol is a beta-agonist that works by stimulating beta-2 adrenergic receptors to cause bronchodilation. Beta-blockers can antagonize this effect, potentially leading to increased bronchospasm and worsening asthma symptoms. Therefore, if a client is on beta-blockers, caution must be exercised when administering albuterol.
B) Anticholinergics: Anticholinergics, such as ipratropium, are often used in conjunction with beta-agonists like albuterol to provide synergistic effects in managing asthma. There are no direct contraindications between anticholinergics and albuterol, and they can be used together safely to improve bronchial dilation and mucus clearance.
C) Antihistamines: Antihistamines are not contraindicated with albuterol. While they may be used for managing allergic reactions and symptoms, they do not interfere with the action of beta-agonists. Therefore, a client taking antihistamines can still safely receive albuterol for acute asthma attacks.
D) Glucocorticoids: Glucocorticoids, such as prednisone, are often used in asthma management for their anti-inflammatory properties. They are not contraindicated with albuterol; in fact, they are commonly used together in asthma treatment plans. Glucocorticoids help to reduce airway inflammation, while albuterol provides quick relief from bronchospasm.