During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and agitated, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission?

Choice A reason: Bending at the knees lowers the nurse’s center of gravity, enhancing stability during lifting. This engages leg muscles (quadriceps, glutes), reducing spinal strain and fall risk. Proper body mechanics protect the nurse’s musculoskeletal system and ensure safe client transfer post-surgery, when mobility is limited, making this the correct action.

Choice B reason: Standing with feet 3 inches apart provides insufficient balance, as a wider stance (12-18 inches) stabilizes the body during lifting. Narrow footing increases fall risk, especially with a post-surgical client’s unpredictable movements. Bending at the knees ensures better biomechanical support, making this option inadequate for safe mobility.

Choice C reason: Positioning behind the wheelchair with wheels locked is preparatory but not the primary lifting action. Safe lifting requires bending at the knees to engage leg muscles, minimizing back strain. While locking wheels prevents movement, it does not address the nurse’s body mechanics, making this secondary to proper lifting technique.

Choice D reason: Asking the client to place hands on the nurse’s shoulders risks instability, as post-surgical clients may have weak grip or balance. This shifts weight unpredictably, straining the nurse’s back. Bending at the knees ensures the nurse controls the lift, using leg strength, making this option unsafe for secure transfer.

Choice A reason: Depression may cause fatigue or inattention but is not a direct fall risk. Fall risk involves impaired balance or coordination, often from neurological or musculoskeletal issues. Depression affects serotonin levels, potentially reducing motivation, but does not immediately alter motor function or stability, making it less relevant than opioid-induced sedation.

Choice B reason: Stooped posture with a steady gait suggests postural changes but not immediate fall risk, as steady gait indicates balance. Falls require deficits in coordination or strength, often from neurological or pharmacological causes. Posture may strain muscles but does not directly impair stability, unlike opioids, which cause sedation, making this incorrect.

Choice C reason: Opioid analgesics, received an hour ago, increase fall risk by causing sedation and dizziness. Opioids bind mu receptors, depressing the central nervous system, impairing coordination and reaction time. This neurological effect reduces balance and increases fall likelihood, making it a critical factor to include in the care plan for safety.

Choice D reason: Hemoglobin of 16 g/dL is normal (14-18 g/dL), indicating adequate oxygen-carrying capacity. Low hemoglobin could cause fatigue, increasing fall risk, but normal levels do not. Falls are linked to impaired balance or sedation, like from opioids, not normal hematological status, making this irrelevant for fall risk assessment.