A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Enlist help from another staff member

Avoid movements that twist the spine

Use a powered standing-assist lift

Adjust the bed to an appropriate height

Answer and Explanation

The Correct Answer is C

A reason:

Enlisting help from another staff member is important for safety, but it is not the most specific intervention for this scenario. Using a powered lift ensures a safer and more controlled transfer process.

B reason:

Avoiding movements that twist the spine is good practice for the nurse's safety, but it does not directly address the client's need for assistance during the transfer. Proper lifting techniques are important, but mechanical assistance is preferable for this situation.

C reason:

Using a powered standing-assist lift is the best option. It helps the client who can partially bear weight to transfer safely and reduces the risk of injury to both the client and the nurse. This equipment is designed specifically for such transfers.

D reason:

Adjusting the bed to an appropriate height is a necessary step to facilitate the transfer, but it is not sufficient on its own. Using a lift in addition to adjusting the bed height ensures maximum safety and efficiency during the transfer process.

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Correct Answer is C

Explanation

A reason:

Determining the time the client last received pain medication is important, but it should be done after assessing the current pain level. The nurse needs to know the severity of the pain to decide the next steps.

B reason:

Measuring the client's vital signs, including temperature, is also important, especially to rule out complications like infection. However, addressing the client's immediate pain should take priority to provide relief and then proceed with further assessments.

C reason:

Asking the client to rate her pain on a scale from 0 to 10 is correct. This provides a clear understanding of the pain's intensity, which is essential for determining the appropriate intervention. It allows the nurse to gauge the severity of the pain and respond accordingly.

D reason:

Repositioning the client and offering a back rub can help alleviate discomfort, but these actions should follow the pain assessment to ensure the interventions are appropriate based on the pain's severity and nature.

A. To identify delayed gastric emptying B. To remove gastric acid that might cause dyspepsia C. To determine the client's electrolyte balance D. To confirm the placement of the NG tube

Correct Answer is A

Explanation

A reason:

Identifying delayed gastric emptying is correct. Measuring gastric residual volumes helps to assess whether the stomach is emptying properly. High residual volumes can indicate delayed gastric emptying, which can increase the risk of aspiration and other complications.

B reason:

Removing gastric acid to prevent dyspepsia is not the purpose of measuring gastric residuals. While managing gastric contents is important, the primary reason for checking residuals in this context is to assess gastric emptying.

C reason:

Determining electrolyte balance is not the purpose of measuring gastric residuals. Electrolyte balance is typically assessed through blood tests, not by measuring gastric residuals.

D reason:

Confirming the placement of the NG tube is not the purpose of measuring gastric residuals. Tube placement should be confirmed through initial radiographic verification and regular checks, such as auscultation and pH testing, rather than by measuring residual volumes.

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A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Nursing Test Bank

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Correct Answer is A

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