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 A
Explanation
A. Limit use of the drug to 3 days to prevent rebound nasal congestion: Oxymetazoline is a topical nasal decongestant that can lead to rebound congestion if used for more than three consecutive days. This condition, known as rhinitis medicamentosa, can worsen nasal congestion rather than alleviate it, making it crucial for clients to adhere to this guideline.
B. This drug may be used in maintenance treatment for asthma: Oxymetazoline is not indicated for the maintenance treatment of asthma. It is a nasal decongestant, primarily used for temporary relief of nasal congestion due to colds or allergies, and does not address the underlying inflammation in asthma.
C. This medication may take up to a week to see effects: In fact, oxymetazoline provides rapid relief of nasal congestion, typically within minutes of administration. Clients should expect to feel its effects much sooner rather than having to wait a week, which can lead to misuse or overuse of the medication.
D. Take this drug at bedtime because it may cause drowsiness: Oxymetazoline is not known to cause drowsiness; rather, it works as a decongestant. Patients are usually advised to use it during the day as needed, and it should not be specifically recommended for bedtime use
Correct Answer is A
Explanation
A) Liver injury: Zafirlukast (Accolate) has been associated with the risk of liver injury. It is important for clients to be informed about this potential adverse effect, as it may require monitoring of liver function tests during treatment. Symptoms of liver injury, such as jaundice, dark urine, or severe fatigue, should prompt clients to seek medical attention.
B) Bradycardia: Bradycardia is not a commonly associated adverse effect of zafirlukast. This medication primarily works as a leukotriene receptor antagonist and does not typically affect heart rate significantly. Clients should be aware of other more relevant side effects rather than bradycardia.
C) Renal failure: Renal failure is not a known adverse effect of zafirlukast. While kidney function should always be monitored in patients taking various medications, zafirlukast specifically does not have a direct association with renal failure.
D) Bronchoconstriction: While bronchoconstriction is a concern in asthma management, zafirlukast is designed to prevent bronchoconstriction by blocking leukotriene receptors. Therefore, it is not an adverse effect of the medication. In fact, its purpose is to help reduce the incidence of bronchoconstriction and improve asthma control.