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.

Answer and Explanation

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 C

Explanation

A. Notifying the health care provider is not the most appropriate first action, as parental consent is needed.
B. Contacting the United Network for Organ Sharing is premature without consent from the parents.
C. Since the patient is a minor, parental consent is generally required for organ donation. Instructing the patient to discuss this desire with their parents is essential for obtaining legal consent.
D. Preparing the organ donation form is also premature, as minors cannot legally consent without parental approval.

A. Elevated blood pressure B. Increased pulse rate C. Cyanosis D. Restlessness

Correct Answer is C

Explanation

A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.

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The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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