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 B
Explanation
A. Stimulates effects of histamine by occupying all H receptor sites: This statement inaccurately describes the action of diphenhydramine. Instead of stimulating histamine effects, diphenhydramine actually blocks them, particularly at H1 receptors, which areinvolved in allergic responses.
B. Blocks effects of histamine by competing and occupying H1 receptor sites: This accurately describes the mechanism of action of diphenhydramine. As an antihistamine, it competes with histamine for binding to H1 receptor sites, effectively reducing symptoms of allergies, such as sneezing, itching, and nasal congestion.
C. Blocks effects of histamine by competing and occupying H2 receptor sites: This option is incorrect because H2 receptor antagonists are used primarily to reduce gastric acid secretion, not to treat allergic reactions. Diphenhydramine specifically targets H1 receptors, not H2 receptors.
D. Stimulates effects of histamine by increasing the amount of H2 receptor sites: This statement is also incorrect. Diphenhydramine does not stimulate histamine activity or increase receptor sites. Instead, it functions to inhibit the action of histamine at H1 receptors, which is fundamental in alleviating allergy symptoms.
Correct Answer is A
Explanation
A. Tachycardia: Theophylline can stimulate the heart, leading to an increase in heart rate. Tachycardia is a common adverse effect associated with theophylline use, and it is essential for the client to be aware of this potential side effect, especially if they have underlying heart conditions.
B. Constipation: While gastrointestinal side effects can occur with theophylline, constipation is not a primary or common adverse effect. Theophylline may actually lead to gastrointestinal upset or increased gastric acid production rather than causing constipation.
C. Drowsiness: Theophylline typically does not cause drowsiness. In fact, it is more likely to
cause restlessness or insomnia, as it is a stimulant. Thus, advising the client about drowsiness is not relevant in this case.
D. Oliguria: Oliguria (reduced urine output) is not a common adverse effect of theophylline. Theophylline can affect kidney function indirectly but does not typically present as oliguria. Monitoring for any renal changes is essential, but oliguria is not a primary concern.