The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?
Yankauer suction tip catheter
Blood pressure cuff
Oxygen cannula
Pulse oximeter
The Correct Answer is B
A. A Yankauer suction tip catheter is used for suctioning secretions and does not assess cardiac function or afterload.
B. A blood pressure cuff is essential for measuring blood pressure, which can indicate increased afterload through elevated systemic vascular resistance.
C. An oxygen cannula is used for delivering supplemental oxygen and does not provide information about cardiac afterload.
D. A pulse oximeter measures oxygen saturation, which is not directly related to assessing cardiac afterload.
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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.
Correct Answer is ["A","D"]
Explanation
A. Turning the clean pillowcase inside out over the hand holding it helps avoid contamination and allows easy application.
B. Soiled linens should be kept away from the nurse's uniform to prevent cross-contamination; hence, this is incorrect.
C. Sterile gloves are not required for bed-making; clean gloves may be used when handling soiled linens.
D. A modified mitered corner keeps the bed neat and helps secure the sheet, blanket, and spread.
E. Advising the patient of a lump when rolling over is not necessary for bed making, as the goal is to provide comfort without lumps.