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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.
Correct Answer is C
Explanation
A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.
B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.
C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.
D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.