A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

Have the client roll onto a transfer board and pull the board onto the stretcher.

Move the client onto the stretcher using a slide board with the assistance of two health care workers.

Apply a transfer belt to the client prior to transferring to the stretcher.

Move the client's upper body onto the stretcher first.

Answer and Explanation

The Correct Answer is B

A. Have the client roll onto a transfer board and pull the board onto the stretcher: Rolling the client onto a transfer board can be difficult and potentially dangerous, especially for an immobile client. It is safer to use a slide board with assistance to ensure the transfer.

B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board, along with the assistance of two health care workers, ensures a safer and more controlled transfer of the immobile client, minimizes the risk of injury to both the client and the healthcare workers.

C. Apply a transfer belt to the client prior to transferring to the stretcher: A transfer belt is used for clients who are able to assist in the transfer, but it is not appropriate for immobile clients. Using a slide board with assistance is safer for transferring a client who is immobile.

D. Move the client's upper body onto the stretcher first: It is important to maintain a proper and safe method by transferring the entire body at once. Moving the upper body first could result in uneven weight distribution and increase the risk of injury during the transfer.

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Correct Answer is D

Explanation

A. Oral temperature 37.4°C (99.3°F): This is a low-grade fever and is generally not concerning unless it increases or persists. It could be related to the body’s response to surgery but does not require immediate reporting to the provider.

B. BP 130/84 mm Hg: This is a normal blood pressure for most adults and does not indicate an issue. There is no immediate concern for the nurse to report this to the provider.

C. Heart rate 88/min: A heart rate of 88 beats per minute is within normal range for an adult and does not require reporting to the provider.

D. Respiratory rate 10/min: A respiratory rate of 10/min is significantly below the normal range for an adult (12-20 breaths per minute) and could indicate respiratory depression, a common side effect of opioid analgesics. This is a serious finding and should be reported to the provider immediately for further evaluation and intervention.

A. Depression B. Bargaining C. Denial D. Acceptance

Correct Answer is D

Explanation

A. Depression: Depression typically involves feelings of sadness, despair, and withdrawal. The client's statement about wanting comfort, rather than prolonged sadness, reflects acceptance, not depression.

B. Bargaining: Bargaining is when individuals try to make deals to reverse their situation, often asking for more time. The client’s statement reflects a decision to stop treatment, not bargaining for more time.

C. Denial: Denial involves refusing to acknowledge the reality of the situation. The client’s statement shows recognition of their condition and prioritizing comfort, which shows acceptance rather than denial.

D. Acceptance: In the acceptance stage, individuals come to terms with their diagnosis and focus on achieving peace. The client’s request for comfort care is consistent with acceptance, where they focus on making the most of their time.

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A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

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