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","C"]
Explanation
A) Decongestants: These medications are primarily used to relieve nasal congestion associated with upper respiratory conditions such as allergic rhinitis and the common cold. They work by constricting blood vessels in the nasal passages, thereby reducing swelling and congestion. Common examples include pseudoephedrine and phenylephrine.
B) H2 Antagonist: H2 antagonists are primarily used to reduce gastric acid secretion and treat conditions such as peptic ulcers and gastroesophageal reflux disease (GERD). They are not indicated for upper respiratory conditions, so this option does not apply.
C) H1 Antagonist: H1 antagonists, or antihistamines, are used to alleviate symptoms of allergies, hay fever, and other upper respiratory conditions by blocking the effects of histamine. This class includes both first-generation antihistamines (like diphenhydramine) and second-generation antihistamines (like cetirizine), making them relevant for upper respiratory issues.
D) Long-Acting Beta Agonist (LABA): LABAs are primarily used for the management of asthma and chronic obstructive pulmonary disease (COPD), targeting the lower respiratory tract. They are not typically used for upper respiratory conditions, so this option does not apply.
E) Short Acting Beta Agonist (SABA): SABAs, such as albuterol, are primarily used for acute asthma attacks and bronchospasm in conditions like COPD. They act on the lower respiratory tract and are not indicated for upper respiratory conditions.
F) Mast Cell Stabilizers: These medications are used to prevent allergic reactions and asthma symptoms by stabilizing mast cells and preventing the release of histamine and other inflammatory mediators. While they may have a role in allergic rhinitis, they are not the primary treatment for upper respiratory tract conditions, making this option less applicable compared to decongestants and H1 antagonists.
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.