The nurse is measuring the client’s blood pressure. She will record which of the following as the “Systolic” blood pressure?

Choice A reason: This option is inappropriate because the client is non-verbal and cannot confirm their identity verbally. Asking them to state their birthday would not be effective in this situation.

Choice B reason: This is the correct action because checking the client’s identification band and comparing the MRN and picture in the chart aligns with National Patient Safety Goals. It ensures accurate patient identification using two identifiers, which is critical to prevent errors in treatment, medication administration, and procedures.

Choice C reason: This option is unsafe because room numbers are not reliable identifiers. Patients may be moved to different rooms, and relying on location can lead to misidentification and serious errors.

Choice D reason: This option is inappropriate because relying on another nurse’s memory or familiarity is not a standardized or safe method of identification. Patient identification must be verified using official identifiers, not personal recognition.

Choice A reason: Instructing the patient to push off the locked wheelchair provides stability and safety during transfer. Locking the wheelchair prevents movement and reduces fall risk.

Choice B reason: Holding the patient away from the nurse’s uniform is not a therapeutic or safety-based action. The focus should be on secure handling, not uniform contact.

Choice C reason: Securing the gait belt just below the patient’s hips ensures proper leverage and support during transfer. It allows the nurse to guide movement safely and reduces strain on both patient and caregiver.

Choice D reason: Raising the bed above the nurse’s waist increases risk of injury to the nurse and makes transfer unsafe. The bed should be adjusted to a safe height for both patient and caregiver.