The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)
Turn clean pillowcase inside out over the hand holding it.
Keep soiled linen close to uniform.
Apply sterile gloves.
Make a modified mitered corner with sheet, blanket, and spread.
Advise patient will feel a lump when rolling over.
Correct Answer : A,D
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.
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Correct Answer is D
Explanation
A. Grief evaluation refers to assessing the grief process rather than actively engaging in supportive dialogue, which is not the primary focus of the nurse's action.
B. Pain-management techniques would not apply directly to this context, as the discussion centers on emotional support rather than physical pain.
C. Palliative care encompasses a broader approach to managing patients with serious illnesses but does not specifically address the emotional support provided in this situation.
D. The nurse's action of discussing the child's life and death helps the parents express their grief and memories, thereby facilitating normal mourning, making this the most appropriate principle demonstrated.
Correct Answer is B
Explanation
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.