A nurse is caring for a client who has dehydration and reports muscle cramps and constipation. Which of the following laboratory values should the nurse expect?

Rationale

A. "I will be available for you until your family arrives.": This response provides emotional support and reassurance, addressing the client’s anxiety about undergoing the procedure alone. It demonstrates presence, empathy, and commitment to the client’s safety and comfort.

B. "I'm sure your family will be here soon.": This statement offers false reassurance because the nurse cannot guarantee the family’s arrival time. It may minimize the client’s feelings and does not provide immediate emotional support.

C. "You'll feel better once this procedure is over.": This focuses on the outcome rather than the client’s current emotional distress. It may invalidate the client’s feelings and does not offer support in the present moment.

D. "Why do you think your family is delayed?": Asking “why” can seem judgmental or accusatory and may increase the client’s anxiety. It does not provide comfort or address the immediate need for support before the procedure.

Rationale

A. Apply a transfer belt to the client prior to transferring to the stretcher: Transfer belts are used for clients who can stand or provide some degree of weight-bearing support. An immobile 104.3-kg client cannot safely assist with the transfer, making the belt ineffective and unsafe. Using a transfer belt in this scenario increases the risk of falls and caregiver injury.

B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board reduces friction and allows the client to be moved laterally as a single unit, which is the safest method for an immobile client of this weight. Using at least two trained staff members prevents strain and ensures coordinated movement.

C. Have the client roll onto a transfer board and pull the board onto the stretcher: This technique requires the client to participate by rolling, which is not feasible for someone who is immobile. Pulling a transfer board with the client on it creates unnecessary shear forces that increase the risk of skin breakdown. This approach is neither safe nor appropriate for a heavy, immobile patient.

D. Move the client's upper body onto the stretcher first: Moving the client unevenly in sections can cause spinal misalignment and increases the risk of caregiver injury due to poor body mechanics. This technique also creates friction on the client’s skin and may cause discomfort or tissue injury. A coordinated lateral transfer keeps the body aligned and is recommended.