The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?
Performing chest percussion on a client with atelectasis
Auscultate lungs on a client with audible wheezing
Taking vital signs on a male client with severe dyspnea
Suctioning a client with hemoptysis (bloody sputum)
Setting up a meal tray for a client with COPD
The Correct Answer is E
A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.
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Correct Answer is ["A","C"]
Explanation
A. Pulmonic valve closure is best heard at the base of the heart, near the second intercostal space at the left sternal border.
B. Tricuspid valve sounds are best heard at the lower left sternal border, near the apex rather than the base of the heart.
C. Aortic valve closure is also best heard at the base of the heart, near the second intercostal space on the right sternal border.
D. Mitral valve sounds are heard best at the apex of the heart, near the fifth intercostal space in the midclavicular line, not the base.
Correct Answer is A
Explanation
A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.