A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)

Correct Answer: C

Rationale: The correct answer is C because ensuring the client wears TED hose or sequential compression devices is within the scope of practice for UAP. This task does not require critical thinking or assessment skills, making it suitable for delegation. Administering antibiotics (A) and encouraging spirometer use (B) require clinical judgment and assessment skills, which UAP do not possess. Having the client rate pain and report to the nurse (D) involves subjective assessment and potential interventions, making it inappropriate for delegation to UAP.

Correct Answer: D

Rationale: In smoking cessation education, it is crucial to provide accurate information and strategies to support individuals in their journey to quit smoking. The correct answer, "D) Drink at least eight glasses of water each day," is not directly related to smoking cessation. While staying hydrated is important for overall health, it is not a specific or essential strategy for quitting smoking. Option A is a helpful strategy as finding alternative activities can distract from cravings and keep hands busy, reducing the urge to smoke. Option B is also important as identifying personal reasons for quitting can increase motivation and commitment. However, option C, "Identify a punishment for yourself in case you backslide," is not recommended as punishment may lead to feelings of guilt or failure, hindering progress in smoking cessation. In an educational context, emphasizing positive reinforcement, behavior modification techniques, coping strategies for cravings, and social support are more effective approaches to include in smoking cessation teachings. Providing evidence-based practices and supportive guidance can empower individuals to successfully quit smoking and improve their health outcomes.

Correct Answer: C

Rationale: In this scenario, the correct intervention to delegate to the student nurse is to assess the ECG strip for tall T waves (Option C). Rationale: Elevated potassium levels (hyperkalemia) can lead to serious cardiac complications, including dysrhythmias such as ventricular tachycardia or fibrillation. Tall T waves on an ECG are indicative of hyperkalemia. By delegating the task of assessing the ECG strip to the student nurse, you are allowing them to apply their knowledge of ECG interpretation to recognize a critical finding and alert the healthcare team promptly. Why other options are wrong: - Option A: Administering Kayexalate orally is not appropriate for an acute situation of hyperkalemia as it works in the intestines to exchange sodium for potassium, which is a slower process. - Option B: Spironolactone is a potassium-sparing diuretic and can further increase potassium levels, making it contraindicated in hyperkalemia. - Option D: Administering more potassium orally is contraindicated in the setting of hyperkalemia as it can exacerbate the condition. Educational context: Understanding the management of electrolyte imbalances, such as hyperkalemia, is crucial in pharmacology and medical-surgical nursing. Teaching students to recognize ECG changes associated with hyperkalemia equips them with the skills to identify and respond to critical situations promptly, promoting patient safety and quality care. This rationale provides a comprehensive explanation of the correct intervention and reinforces the importance of ECG monitoring in patients with electrolyte disturbances.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Serum magnesium 0.8 mEq/L. The reason this result is of most concern is that magnesium plays a crucial role in various physiological processes, including muscle and nerve function, regulation of blood sugar levels, and bone development. A low serum magnesium level can lead to serious complications such as arrhythmias, muscle weakness, and seizures. Therefore, prompt intervention is necessary to address this abnormality. When analyzing the other options: A) Serum potassium 5.2 mEq/L: While slightly elevated, this potassium level is within a normal range (3.5-5.0 mEq/L) and would not typically cause immediate concern. B) Serum sodium 134 mEq/L: This sodium level is within the normal range (135-145 mEq/L) and does not indicate any imminent issues. C) Serum calcium 10.6 mg/dL: This calcium level is slightly elevated, but hypercalcemia would usually present with more severe symptoms, making it less concerning than a critically low magnesium level. In an educational context, it is essential for healthcare professionals to understand the significance of abnormal laboratory results and prioritize their interpretation based on the potential impact on a patient's health. This question highlights the importance of recognizing the critical nature of certain electrolyte imbalances and the need for timely intervention to prevent adverse outcomes in patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Respiratory alkalosis. An elevated respiratory rate of 38 breaths per minute indicates hyperventilation, leading to excessive loss of carbon dioxide (CO2) from the body. This results in a decrease in carbonic acid concentration, leading to respiratory alkalosis. Option A) Respiratory acidosis is incorrect because it would present with a low respiratory rate and an increase in CO2 levels, leading to acidosis. Option C) Metabolic acidosis is incorrect as it is related to non-respiratory factors like renal failure or diabetic ketoacidosis. Option D) Metabolic alkalosis is incorrect as it is related to excessive loss of acid or gain of bicarbonate not due to respiratory causes. Educationally, understanding acid-base imbalances is crucial in pharmacology as it impacts drug distribution, metabolism, and elimination. Nurses need to recognize these imbalances to provide appropriate interventions and prevent complications for patients. This question highlights the importance of assessing vital signs and recognizing respiratory alkalosis based on specific clinical manifestations.