A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
Sequential compression devices
Elastic stockings
Thermometer
Blood pressure cuff
The Correct Answer is D
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.
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Correct Answer is A
Explanation
A. After a nurse is exposed to blood from a cut by a used scalpel, it is crucial to test the patient for bloodborne pathogens (e.g., HIV, hepatitis B, hepatitis C) and to offer post-exposure prophylaxis or treatment to the nurse if indicated.
B. While removing gloves and disposing of them properly is part of standard infection control practices, it is not the primary process required after an exposure incident.
C. Although the nurse should report the incident, providing a medical evaluation should follow the protocols established by the facility, not just the manager's assessment.
D. Properly disposing of the scalpel in a sharps container is necessary for safety but does not directly address the required process for managing exposure to blood.
Correct Answer is D
Explanation
A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.