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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A) Montelukast (Singulair): This medication is a leukotriene receptor antagonist used to manage asthma and allergic rhinitis. It does not contain soy or soy-derived ingredients, making it a safe option for a client with a soybean allergy. There are no known contraindications related to soy in this medication.
B) Methylprednisolone (Solumedrol): This is a corticosteroid used to reduce inflammation. It is not contraindicated for clients with a soybean allergy, as it does not contain soy-derived components. The medication primarily poses risks related to long-term use, but not specifically regarding soybean allergies.
C) Ipratropium bromide (Atrovent): This medication is an anticholinergic used to relieve bronchospasm. Ipratropium bromide is formulated with soy lecithin, which is derived from soybeans. Therefore, it is contraindicated for clients with a known allergy to soybeans, as it may trigger an allergic reaction.
D) Albuterol (Ventolin): This medication is a short-acting beta-agonist used for quick relief of bronchospasm. It does not contain any soy components and is generally safe for patients with soybean allergies. While there may be other considerations for its use, the allergy to soy is not a concern with this medication.
Correct Answer is B
Explanation
A. Hypertension: Fluticasone, a corticosteroid, is not typically associated with causing hypertension directly. However, chronic use can lead to fluid retention and hypertension in some individuals, but it is not a primary concern compared to other side effects.
B. Fungal infections: This is a significant adverse effect associated with inhaled corticosteroids like fluticasone. Prolonged use can increase the risk of oral thrush and other fungal infections due to the immunosuppressive effects of corticosteroids. Monitoring for signs of infection is crucial.
C. Decreased immunity: While long-term use of systemic corticosteroids can lead to decreased immune function, inhaled fluticasone is less likely to cause significant immunosuppression. However, it can still impact local immunity in the airways, making monitoring for infections more relevant than generalized immune suppression.
D. Hypoglycemia: Fluticasone is not known to cause hypoglycemia. In fact, corticosteroids typically can lead to increased blood glucose levels rather than lowering them, especially with chronic use, making this option inaccurate in the context of monitoring for adverse effects.