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 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.
Correct Answer is D
Explanation
A. Assuming that both have the same spiritual beliefs can lead to misunderstandings; individual beliefs can vary significantly even within the same affiliation.
B. Skipping the spiritual belief assessment is inappropriate as it is essential to understand the patient's unique beliefs and values to provide holistic care.
C. While a formal assessment tool can be helpful, it is not mandatory; what’s most important is engaging in a dialogue about the patient’s beliefs rather than strictly following a formal method.
D. It is crucial for the nurse to respect the patient's unique spiritual beliefs and not impose personal values, making this the most appropriate action to support the patient spiritually.