Which of the following client situation is appropriate to delegate to a (n) unlicensed assistive personnel (UAP)? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A because assisting a client with a 1:1 feeding is within the scope of practice for unlicensed assistive personnel (UAP). UAPs can provide basic assistance with feeding under the supervision of a licensed nurse. This task does not require specialized nursing skills. Choice B is incorrect because emptying a foley catheter drainage bag involves a sterile procedure that should be performed by a licensed nurse. Choice C is incorrect as assessing a client with new onset shortness of breath and taking vital signs requires critical thinking and clinical judgment, which are beyond the scope of practice for UAPs. Choice D is incorrect because providing information about discharge home health services involves patient education and coordination of care, which are responsibilities of the licensed nurse or healthcare provider.

Correct Answer: C

Rationale: The correct answer is C. Assess the respiratory status and pulse oximeter reading. This is the first intervention the nurse should implement because it provides crucial information about the client's current oxygenation status and respiratory function. By assessing these parameters, the nurse can quickly identify any immediate issues that may require intervention, such as respiratory distress or hypoxemia. Confirming ventilator settings (A) and verifying ventilator alarms (B) are important tasks but assessing the client's respiratory status takes priority as it directly impacts the client's oxygenation and ventilation. Monitoring arterial blood gas results (D) is important for evaluating the effectiveness of ventilation but is not the first step in managing a client on a ventilator.

Correct Answer: C

Rationale: The correct answer is C: Pulmonary embolus. A V/Q lung scan is used to evaluate the ventilation-perfusion ratio in the lungs. A mismatch ratio greater than 1 indicates a significant ventilation-perfusion mismatch, which is commonly seen in pulmonary embolism where there is a blockage in the pulmonary artery. This leads to decreased perfusion in areas of the lung, causing the mismatch. Therefore, when the mismatch ratio is greater than 1, pulmonary embolus should be suspected. Choices A, B, and D do not directly correlate with a mismatch ratio on a V/Q lung scan, making them incorrect in this context.

Correct Answer: B

Rationale: The correct answer is B, impaired gas exchange due to alveolar-capillary membrane damage. In ARDS, inflammation and injury to the alveolar-capillary membrane lead to increased permeability and fluid accumulation, impairing gas exchange. Reduced hemoglobin levels (choice A) do not directly cause hypoxemia in ARDS. Decreased perfusion to pulmonary capillaries (choice C) may contribute to hypoxemia but is not the primary mechanism in ARDS. Increased airway resistance due to bronchoconstriction (choice D) affects ventilation, not gas exchange, and is not the primary cause of hypoxemia in ARDS.

Correct Answer: B

Rationale: The correct answer is B: Cardiac output and blood pressure. In ARDS patients on high PEEP, monitoring cardiac output and blood pressure is crucial due to the risk of hemodynamic compromise. High PEEP can decrease venous return, leading to decreased cardiac output and hypotension. Monitoring these parameters helps detect and prevent complications like hypotension, which can further compromise oxygenation. Choice A is incorrect because while monitoring respiratory rate and depth is important in ARDS, the priority in this scenario is monitoring hemodynamic status due to the potential impact of high PEEP on cardiac function. Choice C is incorrect as monitoring white blood cell count is not directly related to complications of high PEEP in ARDS patients. Choice D is incorrect because sputum production and characteristics are not the priority for monitoring in this scenario; cardiac output and blood pressure are more critical indicators of potential complications.