The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

Correct Answer: C

Rationale: In the context of nursing delegation principles, the correct answer is option C, assisting the client with ambulation, as it falls within the scope of practice for unlicensed assistive personnel (UAP). UAPs are trained to provide direct client care tasks that do not require nursing judgment or assessment. They can safely assist clients with activities of daily living, such as ambulation, under the supervision of a registered nurse. Option A, assessing the client's ability to ambulate safely, involves a nursing assessment and requires critical thinking skills to determine the client's readiness for ambulation. This task should be performed by a registered nurse. Option B, documenting the client's tolerance of ambulation, involves recording and interpreting client data, which requires nursing judgment and accountability. This task is the responsibility of the nurse to ensure accurate documentation of the client's condition. Option D, evaluating the client's pain level after ambulation, involves assessing the client's response to ambulation and making decisions based on this assessment. This task requires nursing assessment and intervention to address any pain issues effectively. Educationally, understanding the principles of delegation is crucial for nurses to provide safe and efficient care. By knowing which tasks can be delegated to UAPs and which require nursing expertise, nurses can prioritize their responsibilities and ensure that each team member is working within their scope of practice to promote optimal patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Administer 50% dextrose IV push. In this scenario, the client with type 1 diabetes mellitus is experiencing hypoglycemia with symptoms of confusion and sweating, indicating a severe drop in blood sugar levels. The priority action is to rapidly raise the blood sugar to a safe level to prevent further complications such as seizures, coma, or even death. Administering 50% dextrose IV push provides a quick and direct source of glucose to rapidly increase the blood sugar levels. Option B) Provide a carbohydrate snack is not the priority action in this situation because the client is experiencing severe hypoglycemia, and oral intake may not be effective or fast enough to raise the blood sugar levels to a safe range. Option C) Checking the client's urine for ketones is important in managing diabetes, especially type 1, to assess for diabetic ketoacidosis. However, in this acute situation of hypoglycemia, treating the low blood sugar is the immediate priority. Option D) Starting an insulin drip is contraindicated in a client experiencing hypoglycemia as it will further lower the blood sugar levels, worsening the client's condition. Educationally, this scenario highlights the critical importance of recognizing and promptly treating hypoglycemia in clients with diabetes, particularly type 1. Nurses must be able to assess and manage hypoglycemic episodes effectively to prevent serious complications and ensure client safety. Prioritizing actions based on the client's condition and immediate needs is crucial in emergency situations involving clients with diabetes.

Correct Answer: B

Rationale: In this scenario, the nurse's first action should be to discontinue the antibiotic (option B). This is because the client is exhibiting signs of a potential allergic reaction to the medication, as evidenced by the development of a rash and difficulty breathing. Discontinuing the antibiotic is crucial to prevent further adverse reactions and ensure the client's safety. Administering epinephrine (option A) is not appropriate as the client's symptoms do not indicate an anaphylactic reaction that would warrant the use of epinephrine. Assessing the client's oxygen saturation (option C) is important, but in this case, discontinuing the potentially offending medication takes precedence to address the immediate allergic reaction. Calling the healthcare provider (option D) is important, but not the first action to take when the client is experiencing respiratory distress and a rash. Educationally, this question highlights the importance of recognizing and managing allergic reactions to medications promptly in clinical practice. It emphasizes the need for nurses to prioritize patient safety by taking swift and appropriate actions when faced with signs of adverse drug reactions. Understanding the appropriate steps to take in such situations is crucial for providing high-quality patient care.

Correct Answer: A

Rationale: In caring for a client with an exacerbation of COPD, the most important intervention to promote effective breathing is to encourage diaphragmatic breathing (Option A). Diaphragmatic breathing helps the client maximize the use of their diaphragm, the main muscle of respiration, leading to improved oxygen exchange and ventilation. This technique also reduces the work of breathing and helps the client achieve better oxygen saturation levels. Increasing the client's oxygen flow rate (Option B) may seem beneficial, but it does not address the underlying issue of ineffective breathing mechanics that diaphragmatic breathing targets. Having the client perform range of motion exercises (Option C) and placing them in a supine position (Option D) can actually worsen respiratory distress in COPD by reducing lung expansion and increasing the workload of breathing. In an educational context, understanding the importance of diaphragmatic breathing in COPD management highlights the significance of optimizing respiratory function through evidence-based interventions. By prioritizing this technique, nurses can effectively support clients with COPD in improving their breathing patterns and overall respiratory status, ultimately enhancing patient outcomes and quality of life.

Correct Answer: C

Rationale: In caring for a client with a chest tube post-lung surgery, maintaining proper chest tube function is critical for the client's respiratory status and overall recovery. The most important intervention to ensure the chest tube functions properly is to keep the drainage system below chest level (Option C). This is essential to facilitate proper drainage of air or fluid from the pleural space, creating a gravity-driven flow that prevents backflow or blockages in the tubing. Clamping the tube if there is excessive drainage (Option A) is incorrect because clamping can lead to a tension pneumothorax, a life-threatening complication. Emptying the drainage chamber every 2 hours (Option B) is important but not the most critical intervention as the key lies in maintaining the positioning of the drainage system. Milking the tube to prevent clots (Option D) is incorrect as this action can damage the tube and lead to clots or blockages. Educationally, understanding the rationale behind each intervention enhances a nurse's clinical decision-making skills and promotes safe and effective patient care. Emphasizing the importance of proper chest tube management in postoperative care ensures optimal patient outcomes and reduces the risk of complications associated with chest tube placement.