A nurse is preparing to clean a blood spill on a bedside table. Which of the following solutions should the nurse plan to use?

Correct Answer: C

C. Flex hips and knees when assisting the client to a standing position.Flexing the hips and knees protects the nurse’s back by using proper body mechanics and distributes the force of lifting safely. This position provides stability and reduces the risk of injury to both the nurse and the client during the transfer.

Incorrect answers:

A: "Stand on the client's stronger side when moving the client into the chair."The nurse should stand on the weaker side, not the stronger side, to provide support and assistance where it is most needed. This ensures the client is stabilized and prevents falls or instability due to the weaker side giving way.

B: "Pivot on the foot farthest from the bed when assisting the client into the chair."The nurse should pivot on the foot closest to the chair or the bed to maintain balance and stability. Pivoting on the farthest foot could lead to poor body mechanics and an increased risk of injury to the nurse or client.

D: "Raise the bed to waist level before moving the client." For transferring a client to a chair, the bed should be lowered to a position where the client’s feet can touch the floor. This provides stability and facilitates a safe transfer.

Choice A Reason:

Stomach contents are yellowish-green in color is incorrect. While the color of stomach contents might indicate various aspects of digestion or bile presence, a yellowish-green color alone might not necessarily be an immediate cause for concern unless accompanied by other symptoms or indications of a problem.

Choice B Reason:

Aspirated stomach contents' pH measures 6.5 is incorrect. A pH of 6.5 in aspirated stomach contents might indicate a less acidic environment, but it's not usually considered significantly abnormal. However, it's still essential to consider the context and the individual client's situation when interpreting pH values.

Choice C Reason:

Residual volume of stomach contents measures 90 mL is correct. A residual volume of 90 mL is considered high and could indicate delayed gastric emptying or potential issues with the client's ability to tolerate or absorb feedings. Reporting this finding to the provider is essential for further assessment and potential adjustments in the client's care plan.

Choice D Reason:

Hyperactive bowel sounds are present is incorrect. Hyperactive bowel sounds might suggest increased peristalsis or bowel activity. While this finding may be noted and monitored, it might not require immediate reporting unless it's associated with other concerning symptoms or complications.