A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Rock the client up to a standing position.
Apply a gait belt to the client.
Pivot on the foot that is the farthest from the chair.
Assess the client for orthostatic hypotension.
The Correct Answer is D
Choice A rationale
Rocking the client to a standing position is an implementation step used during the actual transfer process. However, this should only occur after the nurse has ensured the client is physiologically stable enough to tolerate the change in position. Moving directly to this step without checking for hemodynamic stability could lead to a fall if the client experiences sudden dizziness. Safety protocols require assessment of vital signs and physical readiness before any manual handling or movement.
Choice B rationale
Applying a gait belt is a critical safety intervention that provides the nurse with a secure point of contact to assist with the client's balance and stability. While it is a necessary part of the transfer process, it is not the very next step after securing the environment. The nurse must first determine if the client can safely transition from a supine to a sitting position without experiencing adverse physiological symptoms that would make the transfer unsafe.
Choice C rationale
Pivoting on the foot farthest from the chair is a specific technical maneuver used to align the body correctly during the transfer to prevent musculoskeletal strain for both the nurse and the client. This action occurs at the end of the transfer sequence. Before reaching this point, the nurse must have already assessed the client's ability to stand and ensured that the client's blood pressure has stabilized following the change in their physical orientation.
Choice D rationale
Assessing for orthostatic hypotension is the priority next step because changing positions from supine to sitting or standing can cause a rapid drop in blood pressure. This drop occurs due to the gravitational pooling of blood in the lower extremities, which can lead to cerebral hypoperfusion and syncope. Identifying a decrease in systolic pressure ≥ 20 mmHg or diastolic pressure ≥ 10 mmHg is vital to prevent falls and ensure the client's safety during the transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In the I-SBAR-R communication tool, the assessment component focuses on the nurse's current clinical findings and observations regarding the patient's status. Stating that the respiratory rate is 38 per minute provides a specific, objective clinical measurement that indicates the patient is in acute respiratory distress. The normal adult respiratory rate is 12 to 20 breaths per minute. Reporting this data allows the provider to understand the severity of the situation based on the nurse's immediate physical assessment.
Choice B rationale
Mentioning the history of COPD belongs in the background section of the I-SBAR-R tool. The background component provides context for the current situation by detailing the patient's medical history, previous treatments, or allergies. While this information is vital for the provider to understand the patient's baseline and underlying pathology, it is not part of the active assessment of the current acute problem. The assessment section should instead prioritize the current vital signs and physical manifestations.
Choice C rationale
Asking if the supplemental oxygen should be increased is part of the recommendation component of the I-SBAR-R tool. In the recommendation phase, the nurse suggests a specific intervention or asks for a particular order to address the problem identified in the assessment. While this is a critical part of the communication process, it occurs after the nurse has presented the assessment data. The recommendation is the final step where the nurse advocates for the patient's needs.
Choice D rationale
Stating the intention to obtain a sputum culture is also part of the recommendation or plan of action. It reflects a diagnostic step that the nurse proposes or anticipates based on the assessment findings. The assessment component itself is strictly for reporting what the nurse has observed or measured, such as breath sounds, oxygen saturation, or respiratory effort. Proposing future actions belongs at the end of the report to facilitate clear orders from the healthcare provider.
Correct Answer is D
Explanation
Choice A rationale
While advanced practice nurses like nurse practitioners can diagnose and treat, the statement implies that all experienced nurses have this independent authority. In many settings, the registered nurse functions within a collaborative scope and follows established protocols or physician orders. Claiming independent medical ordering for all nurses is inaccurate and misrepresents the legal scope of practice. The role of the nurse is distinct from the medical model, focusing more on holistic care and patient advocacy.
Choice B rationale
Making a medical diagnosis is specifically the legal responsibility of a physician or a licensed healthcare provider with prescriptive authority. While nurses are indeed at the bedside and identify physiological changes, they provide a nursing diagnosis rather than a medical one. Nurses observe symptoms and report findings to the medical team for formal diagnosis. Confusing these roles can lead to legal complications and a misunderstanding of professional boundaries. The nurse's expertise lies in monitoring and managing the patient's health status.
Choice C rationale
Stating that nurses do everything is an overgeneralization that fails to define the unique and specialized scope of the profession. While nurses are versatile and work across various departments, their work is guided by specific standards of practice and ethical codes. This description lacks the scientific and professional rigor that characterizes modern nursing. It ignores the collaborative nature of healthcare where different disciplines contribute specific expertise. Nursing is a distinct science centered on the patient's response to their health condition.
Choice D rationale
This statement accurately reflects the definition of nursing as a profession. Nurses focus on the human response to actual or potential health problems, encompassing physical, emotional, and social aspects. This includes managing symptoms, providing comfort, and promoting health through education and intervention. It distinguishes nursing from medicine by highlighting the holistic approach to how a patient experiences and copes with illness. This role is essential for ensuring patient safety and improving quality of life during and after medical treatment.
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