A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
Patient will turn side to back to side with assistance every 2 hours.
Patient will use the walker correctly to ambulate to the bathroom as needed.
Patient will use a sliding board correctly to transfer to the bedside commode as needed.
The Correct Answer is B
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
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Correct Answer is B
Explanation
A. An air vent allowing bubbles into the blood would be unsafe and can cause air embolism, so this option is incorrect.
B. Using tubing with a filter is standard practice for blood transfusions to prevent clots and debris from entering the patient’s bloodstream, making this the correct choice.
C. Mixing additional electrolytes into the blood is not a standard practice during transfusions, as it can cause complications; thus, this option is not appropriate.
D. Two-way valves are not typically used in blood transfusion setups; the goal is to keep the blood product separate from other fluids unless specifically indicated.
Correct Answer is D
Explanation
A. A 3-mL syringe is not appropriate for administering U-500 insulin, as the concentration may not allow for accurate dosing at such a small volume.
B. A U-100 syringe is designed for U-100 insulin and would not provide accurate measurement for U-500 insulin.
C. A needleless syringe may be useful in certain contexts, but it does not specifically provide the necessary precision for insulin dosage.
D. A tuberculin syringe is suitable for administering small doses (like 0.3 mL) and provides more accurate measurement for high-concentration insulin such as U-500.