A nurse is teaching a newly licensed nurse about preventing puncture injuries, Which of the following instructions should the nurse include?

A) Assist the client into a standing position:
While assisting the client into a standing position is necessary for assessing orthostatic hypotension, it should not be the first action. The nurse needs baseline measurements of the client's blood pressure before making any position changes. This ensures that the changes in blood pressure can be accurately attributed to the positional changes, rather than being affected by the initial standing position.

B) Check the blood pressure with the client in a supine position:
The first step in assessing for orthostatic hypotension is to take a baseline blood pressure while the client is lying flat in the supine position. This provides a reference point for comparison when the client changes positions (to sitting and then standing). This helps to detect significant drops in blood pressure when transitioning to an upright position.

C) Determine the client's blood pressure 1 minute after each position change:
While it is important to measure blood pressure after each position change, this action should occur after baseline blood pressure has been taken while the client is in the supine position. Orthostatic hypotension is assessed by measuring blood pressure in three positions: supine, sitting, and standing.

D) Place the client in a sitting position:
Placing the client in a sitting position is a necessary part of the orthostatic hypotension assessment, but it is not the first step. The nurse must first measure the blood pressure while the client is lying down (supine) to establish a baseline for comparison with the blood pressure readings taken after sitting and standing.

A) "I will wear earphones during this test":
This statement is incorrect. The Rinne test is a hearing test used to compare air conduction to bone conduction of sound. It is performed by placing a vibrating tuning fork near the ear canal (for air conduction) and then on the mastoid bone behind the ear (for bone conduction). Earphones are not used in this test.

B) "A small probe is placed inside my ear":
This statement is incorrect. A probe is typically used for other types of hearing tests, such as tympanometry or an auditory brainstem response (ABR) test, not the Rinne test. The Rinne test involves using a tuning fork, not a probe, and the tuning fork is placed near the ear canal (for air conduction) and on the mastoid bone (for bone conduction).

C) "A tuning fork is placed on my head":
This statement is correct. In the Rinne test, the tuning fork is initially struck to produce sound and then placed on the mastoid bone (behind the ear) to test bone conduction. Afterward, the vibrating tuning fork is moved to the front of the ear canal to test air conduction. The purpose of the test is to compare these two types of conduction. If air conduction is better than bone conduction, this suggests normal hearing, while equal or better bone conduction can indicate conductive hearing loss.

D) "Small electrodes are placed on my scalp":
This statement is incorrect. Electrodes on the scalp are typically used in an electroencephalogram (EEG) or other neurodiagnostic tests, not the Rinne test. The Rinne test focuses on hearing and does not require the use of electrodes. It uses a tuning fork to assess how well sound travels through air and bone.