Which task related to pressure ulcer prevention can the nurse delegate to an unlicensed assistive personnel (UAP)?
Teaching nutrition for wound healing
Assessing skin integrity
Choosing the appropriate dressing
Turning and repositioning the client
The Correct Answer is D
A. Teaching nutrition for wound healing: Teaching is a nursing responsibility that requires assessment, individualized planning, and evaluation and should not be delegated to UAP.
B. Assessing skin integrity: Initial and ongoing skin assessment (including staging, risk factors, and clinical judgment) is a licensed-nurse function and cannot be delegated as the primary assessment.
C. Choosing the appropriate dressing: Selection of wound dressings requires clinical judgment, knowledge of wound physiology, and an order from the nurse/physician; this is not within UAP scope.
D. Turning and repositioning the client: Turning and repositioning to relieve pressure is a routine, stable-care activity that can be safely delegated to UAP with clear instructions and documentation expectations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Prevention of wound infection: Pneumatic compression devices do not actively prevent surgical wound infection; infection prevention relies on aseptic technique, antibiotics as indicated, and wound care.
B. Promote circulation of venous blood: These devices intermittently compress the limbs to enhance venous return, reduce venous stasis, and lower the risk of deep vein thrombosis (DVT).
C. Improve mobility: While used when mobility is limited, the devices themselves do not restore or improve the patient’s ability to ambulate.
D. Encourage lung expansion: Lung expansion is promoted by deep-breathing exercises, incentive spirometry, and positioning; pneumatic compression devices target limb circulation rather than pulmonary mechanics.
Correct Answer is C
Explanation
A. Avulsion: Avulsion involves forcible tearing away of tissue, often with a flap or loss of tissue; it may be extensive but implies more tissue loss rather than just jagged edges.
B. Incision: An incision is a clean, straight surgical cut with tidy edges, not torn or irregular.
C. Laceration: A laceration is characterized by torn, irregular wound edges and separation of tissue, matching this description.
D. Ulceration: An ulcer is a crater-like lesion from tissue breakdown (pressure, ischemia, necrosis), not primarily described as torn, irregular edges from trauma.
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