A nurse is planning to transfer a client who weighs 136 kg (300 lb) from a bed to a chair. The client is unable to assist in the transfer. Which of the following actions should the nurse plan to take?
Wrap their arms under the client's axilla to transfer the client.
Use a powered lift to transfer the client.
Use a gait belt to transfer the client.
Use a sliding board to transfer the client.
The Correct Answer is B
Rationale:
A. Wrap their arms under the client's axilla to transfer the client: Manually lifting a heavy, dependent client by placing arms under the axilla is unsafe and can cause serious musculoskeletal injuries to both the nurse and the client.
B. Use a powered lift to transfer the client: A powered mechanical lift is the safest and most appropriate method for transferring a 136-kg (300-lb) client who cannot assist. It prevents strain on healthcare workers, reduces the risk of falls, and ensures a smooth, controlled transfer from bed to chair.
C. Use a gait belt to transfer the client: A gait belt is used only for clients who can bear some weight and actively assist in the transfer. Since this client is unable to help, using a gait belt would not provide adequate support or safety during the transfer process.
D. Use a sliding board to transfer the client: Sliding boards are designed for clients who have upper body strength and can assist by lifting or shifting themselves during the transfer. In this case, the client’s inability to assist makes a powered lift the only safe and feasible option.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.
B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.
C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.
D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.
Correct Answer is D
Explanation
Rationale:
A. Prolonged QT interval: Morphine does not typically cause a prolonged QT interval. QT prolongation is more commonly associated with certain antiarrhythmic or psychotropic medications, not opioid toxicity.
B. Fluid retention: Morphine is not known to cause fluid retention. Signs of toxicity are primarily related to central nervous system and respiratory depression rather than cardiovascular fluid balance.
C. Hyperactive deep tendon reflexes: Morphine toxicity usually depresses neurological function, leading to decreased reflexes rather than hyperactivity. Hyperactive reflexes are not characteristic of opioid overdose.
D. Bradypnea: Respiratory depression, manifested as bradypnea, is a hallmark sign of morphine toxicity. Excessive morphine depresses the brainstem respiratory centers, reducing the rate and depth of respirations, which can be life-threatening if not addressed promptly.
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