A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Move the client using a slider board.

Use an air-assisted transfer device to move the client.

Raise the bed to 5 cm (2 in) above the level of the stretcher.

Position the head of the bed at 25° prior to the transfer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

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Correct Answer is A

Explanation

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

A. "I will clean reusable equipment with isopropyl alcohol before removing it from the client's room.". B. "I will clean my hands with alcohol-based hand sanitizer after removing the client from the bedpan.". C. "I will wear a mask when I am within 3 feet of the client.". D. "I will wear gloves when changing the client's hospital gown.".

Correct Answer is D

Explanation

The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”

Choice A rationale:

Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.

Choice B rationale:

Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.

Choice C rationale:

Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.

Choice D rationale:

Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment

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A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is D

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