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","E"]
Explanation
A. This medication (Benadryl) targets H2 receptors to alleviate symptoms: This statement is incorrect. Diphenhydramine is an H1 receptor antagonist, not an H2 antagonist. H1 receptors are primarily involved in allergic reactions, whereas H2 receptors are related to gastric acid secretion.
B. Take this medication on an empty stomach before breakfast. Drowsiness is a common side effect of diphenhydramine (Benadryl): While drowsiness is indeed a common side effect, taking diphenhydramine on an empty stomach is not necessarily required and may lead to gastrointestinal discomfort. It can be taken with food if preferred.
C. Avoid CNS depressants while taking diphenhydramine (Benadryl): This is an important teaching point. Diphenhydramine can cause sedation, and the use of other CNS depressants (like alcohol or sedatives) can enhance this effect, increasing the risk of excessive drowsiness or other complications.
D. This medication is a 2nd generation antihistamine: This statement is incorrect. Diphenhydramine is actually a first-generation antihistamine. First-generation antihistamines tend to cause more sedation and other side effects compared to second-generation antihistamines, which are less sedating.
E. Paradoxical reactions can be seen with this medication: This is true. In some individuals, particularly children, diphenhydramine can cause paradoxical reactions, such as increased excitability or hyperactivity, rather than the expected sedation. This is an important consideration to discuss with clients.
Correct Answer is A
Explanation
A. This medication is for long-term treatment for asthma: This statement indicates an accurate understanding of montelukast. It is a leukotriene receptor antagonist used for long-term control and management of asthma symptoms and to prevent exercise-induced bronchoconstriction.
B. This medication has a tendency to produce anaphylaxis: This statement is incorrect. While allergic reactions can occur with montelukast, it is not commonly associated with anaphylaxis. Clients should be aware of potential side effects, but anaphylaxis is not a common risk.
C. I can repeat this medication twice prior to seeking medical attention: This statement is misleading. Montelukast is taken once daily for asthma management, and it is not meant to be repeated or used as a rescue medication in acute situations. Clients should seek medical attention for worsening symptoms instead of relying on repeating doses.
D. Bloodwork is required regularly to monitor the therapeutic levels of this medication: This statement is incorrect. Montelukast does not require routine blood monitoring for therapeutic levels, unlike some other medications used for asthma management. It is generally well-tolerated without the need for regular blood tests.