A nurse is planning care for a patient who is immobile and is experiencing urinary retention.
The nurse should plan to monitor the patient for which of the following?

Choice A rationale
Before repositioning a patient, the nurse should first elevate the height of the patient’s bed. This allows the nurse to work at a comfortable height and reduces the risk of injury.
Choice B rationale
While tightening the abdominal muscles can help with lifting and moving, it is not the first action the nurse should take when preparing to reposition a patient.
Choice C rationale
Positioning the feet in line with the shoulders can provide a stable base of support when moving or lifting. However, this is not the first action the nurse should take when preparing to reposition a patient.
Choice D rationale
Pivoting the feet in the direction of the move can help with turning and moving. However, this is not the first action the nurse should take when preparing to reposition a patient.

Choice A rationale
While it’s important for the client to understand the alternatives to the procedure, it’s typically the responsibility of the physician or surgeon to explain these alternatives, not the nurse.
Choice B rationale
One of the nurse’s responsibilities in the informed consent process is to confirm that the client is competent to sign for the procedure. This means ensuring that the client understands the procedure, its risks and benefits, and is making the decision voluntarily.
Choice C rationale
Discussing the risks of the procedure with the client is typically the responsibility of the physician or surgeon, not the nurse.
Choice D rationale
While the nurse may provide some information about what will occur during the procedure, it’s typically the responsibility of the physician or surgeon to provide detailed information about the procedure.