Which action should you delegate to the experienced nursing assistant?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Take vital signs and pulse oximetry reading every 4 hours. This task is appropriate for delegation to an experienced nursing assistant because it involves routine monitoring that does not require advanced clinical judgment. Vital signs and pulse oximetry readings are essential in assessing a client's respiratory status and can provide valuable data for the healthcare team to make informed decisions. Option A, assessing the client's respiratory status every 4 hours, involves a higher level of assessment that requires nursing knowledge and clinical judgment, making it unsuitable for delegation to a nursing assistant. Option C, checking ventilator settings, is a critical task that involves ensuring the machine is correctly set up to support the client's breathing and should only be performed by a qualified healthcare professional. Option D, observing the client's need for suctioning every 2 hours, also requires a certain level of clinical judgment to determine when suctioning is necessary. This task involves assessing the client's respiratory secretions and deciding on the appropriate intervention, which should be done by a licensed nurse. Educationally, understanding the principles of delegation is crucial for healthcare professionals to provide safe and efficient care. Delegation is about entrusting the right tasks to the right person based on their competency levels. By mastering delegation principles, healthcare providers can optimize workflow, improve patient outcomes, and promote effective teamwork within the healthcare setting.

Correct Answer: D

Rationale: The primary principle involved in the various airway clearance devices used for mobilizing secretions is positive expiratory pressure (PEP). PEP devices work by creating pressure in the airways during exhalation, helping to keep the airways open and mobilize secretions effectively. This mechanism facilitates the clearance of mucus and other secretions from the lungs, making it easier for individuals with respiratory conditions to breathe and maintain healthy lung function. Option A) Vibration: While vibration therapy can be used as a complementary technique in airway clearance, it is not the primary principle involved in most airway clearance devices. Vibration helps to loosen mucus in the airways but does not provide the sustained positive pressure needed for effective secretion mobilization. Option B) Inhalation therapy: Inhalation therapy involves the administration of medications via inhalation devices and is not directly related to airway clearance techniques. While inhalation therapy can help manage respiratory conditions, it does not focus on mobilizing secretions from the airways. Option C) Chest physiotherapy: Chest physiotherapy includes a range of techniques such as chest percussion and postural drainage, which are used to assist with airway clearance. While chest physiotherapy can be effective, the primary principle involved in airway clearance devices like PEP devices is the application of positive expiratory pressure during exhalation. Educational context: Understanding the principles behind airway clearance techniques is crucial for healthcare professionals working with patients who have respiratory conditions. Knowledge of how different airway clearance devices work helps in selecting the most appropriate treatment options for individual patients based on their condition and needs. By grasping the mechanisms of action of these devices, healthcare providers can optimize the management of respiratory conditions and improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is D: Occupation and hobbies. This is the highest priority information for the nurse to obtain because it can provide crucial insights into potential respiratory risks or exposures (e.g., smoking, exposure to fumes or pollutants). Understanding the client's occupation and hobbies helps the nurse assess the impact on respiratory health and tailor interventions accordingly. A: Average daily fluid intake is important for overall health but not directly related to respiratory status. B: Neck circumference may be relevant for assessing airway patency in certain conditions, but occupation and hobbies are more pertinent. C: Height and weight are important for general health assessment but do not directly impact respiratory status as much as occupation and hobbies.

Correct Answer: C

Rationale: The correct answer is C: Cerebral hemispheres. The impulse for voluntary muscles for forceful breathing originates in the cerebral hemispheres where conscious control over breathing is regulated. The cerebral cortex sends signals to the respiratory muscles to increase or decrease breathing effort based on the body's needs. The other choices are incorrect because: A: Medulla (Pons) - This region of the brainstem is responsible for automatic breathing control, not voluntary forceful breathing. B: Vagus nerve - The vagus nerve is not directly involved in initiating voluntary breathing movements. D: Spinal cord - While the spinal cord plays a role in coordinating some aspects of breathing, it is not the primary center for voluntary forceful breathing control.

Correct Answer: C

Rationale: The correct answer is C: Erythropoietin. When climbing a mountain, the body experiences reduced oxygen levels, triggering the release of erythropoietin to stimulate red blood cell production and improve oxygen delivery. This helps counteract the effects of high altitude. Explanation of other choices: A: Anti Natriuretic Factor - This hormone regulates sodium and water balance in the body, not directly related to climbing a mountain. B: Adrenaline - Released in response to stress or danger, not specifically related to climbing a mountain. D: Thyroxine - Regulates metabolism and energy levels, not directly related to the physiological response to climbing a mountain.