The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

A. Elevate the bed to a position of comfort for the nurse: While it is important for the nurse to maintain proper body mechanics and comfort during the transfer, the primary focus should be on the safety and comfort of the client. The bed should be elevated to a height that allows for a safe transfer, not just for the nurse's comfort.

B. Lock the wheels of the bed and the wheelchair: This is a crucial safety measure. Locking the wheels prevents both the bed and the wheelchair from moving during the transfer, reducing the risk of falls or injuries for both the client and the nurse. Ensuring stability is essential for a safe and effective transfer.

C. Place the wheelchair at a 90° angle to the bed: While positioning the wheelchair correctly is important, placing it at a 90° angle may not be the best approach for all clients. The wheelchair should generally be positioned close to the bed, either parallel or at a slight angle, to facilitate a smooth transfer and ensure the client's safety.

D. Acquire the help of several people to lift the client: It is typically not necessary to lift the client unless they are unable to assist in the transfer. Instead, proper techniques, such as using a transfer belt or slide board, should be employed to assist the client in moving safely to the wheelchair. Relying on multiple people to lift can also increase the risk of injury to both the client and the staff if not done properly.

A. Place a seat alarm in the client's chair: This action is the most appropriate first step. A seat alarm can alert the nurse if the client attempts to stand or leave the chair, allowing for timely intervention while promoting the client's dignity and autonomy. This approach aims to enhance safety without the use of restraints or medications.

B. Administer lorazepam to the client: While lorazepam may help manage agitation, it should not be the first action taken. Pharmacological interventions should be considered after non-pharmacological strategies have been explored. Additionally, administering medication requires careful assessment of the client’s current state and potential side effects.

C. Apply a vest restraint on the client: Restraints should be used only as a last resort and after all other options have been considered. Applying a vest restraint can lead to increased agitation and feelings of helplessness, which may exacerbate the client’s condition. The nurse should prioritize less restrictive interventions.

D. Place the client in bed with the two side rails raised: This action can pose safety risks, as raising side rails may create a false sense of security and could lead to falls if the client attempts to get out of bed. Additionally, confining the client to bed can lead to increased confusion and agitation. It is important to provide a safe environment that encourages mobility while minimizing the risk of falls.