The student nurses ask the RN if a Foley catheter would be an appropriate intervention to protect intact skin for a patient who is not ambulatory, incontinent, and confused.
The nurse knows that it would be appropriate to ask the physician for an order to place a Foley catheter for this patient.

Choice A rationale

Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP.

Choice B rationale

Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP.

Choice C rationale

PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate.

Choice D rationale

Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP’s scope of practice. .

Choice A rationale

Removing the external fixator for a shower could compromise stabilization of the fracture. External fixators are designed to be left in place to maintain proper alignment and provide structural support for healing bones. Removing the device could introduce unnecessary risks, including increased mobility and potential damage to the fracture site.

Choice B rationale

Prolonged bed rest is not indicated for patients with external fixation devices unless medically necessary. Prolonged immobility can lead to complications such as deep vein thrombosis, muscle atrophy, or joint stiffness. Mobilization should be encouraged as tolerated to support recovery.

Choice C rationale

Proper cleaning of pin insertion sites prevents infection, a major risk with external fixation devices. Using sterile technique to clean the sites daily reduces bacterial colonization. Monitoring for signs of infection such as redness or drainage is critical to avoid osteomyelitis or systemic spread.

Choice D rationale

Prophylactic antibiotics are typically administered perioperatively but are not continued until device removal unless there are specific complications. Prolonged antibiotic use can lead to antimicrobial resistance and should only be used as clinically indicated to prevent or treat infection.