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A nurse is caring for a client who has a wound infection. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? (SELECT ALL THAT APPLY)

Assessing the wound

Emptying the urine from the indwelling catheter bag

Documenting the client's response to the antibiotic

Taking an oral temperature.

Checking for tunneling with a cotton tipped applicator

Answer and Explanation

Correct Answer : B,D

A. Assessing the wound requires specialized training and should be performed by licensed nursing personnel.

B. Emptying the urine from the indwelling catheter bag is within the scope of practice for UAP.

C. Documenting the client's response to the antibiotic requires interpretation and assessment, which should be done by licensed nursing personnel.

D. Taking an oral temperature is within the scope of practice for UAP.

E. Checking for tunneling with a cotton-tipped applicator requires specialized training and should be performed by licensed nursing personnel.

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Correct Answer is A

Explanation

A. A yellow wound color indicates the presence of slough, which is nonviable tissue that needs to be removed to promote healing. Treatment typically involves debridement of the nonviable tissue followed by application of a moist wound dressing.

B. No treatment is not appropriate for a wound with yellow color indicating the presence of nonviable tissue.

C. Barrier cream and foam dressing may be appropriate for protecting intact skin or managing moisture, but they do not address the underlying issue of nonviable tissue.

D. Enhancing air circulation may be beneficial for some wounds, but it does not specifically address the presence of nonviable tissue in the wound.

A. skin irritation. B. loss of the patch. C. Interactions with other medications D. drug overdose.

Correct Answer is D

Explanation

A. Skin irritation is a possible side effect of nitroglycerin patches but is not a reason to remove the patch before starting an intravenous infusion.

B. Loss of the patch is not a primary concern when transitioning from a nitroglycerin patch to an intravenous infusion.

C. While interactions with other medications are possible, they are not the primary reason to remove the nitroglycerin patch.

D. Removing the old nitroglycerin patch before starting the intravenous infusion is essential to avoid the risk of drug overdose, as the patch continues to release medication even after removal.

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A nurse is caring for a client who has a wound infection. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

On admission to the hospital, the nurse notes that the client has a sacral wound that is "yellow" in color. What wound treatment would the nurse expect the health care provider to order?

Correct Answer is A

Explanation

The nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous infusion. The old patch must be removed from the client's body in order to avoid:

Correct Answer is D

Explanation

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