The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Make sure the bed is low, locked, and call light in reach of patient

Ask the client if they have ordered their dinner

Educate the client on the surgical procedure they are scheduled for in the morning

Check that the client is wearing non-skid socks while in bed

Answer and Explanation

The Correct Answer is A

A. Make sure the bed is low, locked, and the call light is in reach of the patient:

This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.

B. Ask the client if they have ordered their dinner:

While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.

C. Educate the client on the surgical procedure they are scheduled for in the morning:

While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.

D. Check that the client is wearing non-skid socks while in bed:

While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.

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Correct Answer is D

Explanation

A. Infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair:

Administering an IV fluid bolus before transferring the client to a chair is not necessary and not directly related to the safe transfer from bed to chair. It doesn't directly assist with the physical transfer process.

B. Obtaining a quad cane for the client to use as a transfer aid:

While a quad cane can be helpful for some individuals with mobility issues, it might not be necessary for the initial transfer from bed to chair and may not be appropriate for everyone.

C. Positioning a friction-reducing sheet under the client:

While a friction-reducing sheet can assist with moving a client, it may not be necessary for the initial transfer from bed to chair, especially if the client can bear weight and perform the transfer safely.

D. Having the client sit on the side of the bed for several minutes before moving to the chair:

This is the best action. Allowing the client to sit on the side of the bed for a few minutes helps the body adjust to being in a sitting position after an extended period of lying down. It allows for gradual adaptation and reduces the risk of dizziness or orthostatic hypotension when moving from lying down to sitting up.

A. Every four hours. B. Every hour. C. Every shift. D. Every two hours

Correct Answer is D

Explanation

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

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The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

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Explanation

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