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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "You should try putting the baby in a carrier so you can take a walk when they start crying.": This response may not address the client's emotional frustration. It's important to first listen and understand the full context before offering advice.
B. "Tell me more about what is going on when the baby starts crying.": This response shows empathy and invites the client to share more about their experience. It allows the nurse to better understand the situation and provide support or guidance tailored to the client’s concerns.
C. "Many parents have told me it gets better when the baby is about 3 months old.": It's important to explore the client’s current experience and feelings rather than assuming their situation will improve without validating their concerns.
D. "As a new parent, you should be enjoying your time with the baby.": This statement may come across as judgmental as it implies the client should be feeling something different. It is important to acknowledge and validate the client's feelings.
Correct Answer is A
Explanation
A. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.
B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.
C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.
D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.
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