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. While anxiety relief is important, holistic care encompasses the patient's overall well-being and not just the alleviation of symptoms.
B. Understanding how anxiety impacts the patient's daily functioning allows for a more comprehensive approach to care, addressing both psychological and practical concerns.
C. It is inappropriate to suggest to the patient that there is little hope for relief, as this can negatively affect their mental health.
D. Focusing solely on quick fixes does not address the underlying issues of chronic anxiety and may not lead to long-term improvements.
Correct Answer is D
Explanation
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.