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 C
Explanation
Rationale:
A. "I will remove gluten from my diet.": Gluten is not associated with latex cross-reactivity. Gluten sensitivity is related to celiac disease, which involves an immune response to wheat proteins, not latex allergens.
B. "I will remove peanuts from my diet.": Peanuts are not part of the common cross-reactive foods for latex allergy. While peanuts are a frequent cause of food allergies, they do not share similar protein structures with latex that trigger cross-sensitivity reactions.
C. "I will remove bananas from my diet.": Bananas share similar protein allergens with natural rubber latex, which can trigger cross-reactive allergic responses. Individuals with latex allergy often react to foods such as bananas, avocados, kiwis, and chestnuts, making avoidance of these foods advisable.
D. "I will remove dairy products from my diet.": Dairy products do not have protein structures similar to those found in latex and are not linked to latex-related cross-reactivity. Removing them from the diet provides no benefit in managing latex allergies.
Correct Answer is A
Explanation
Rationale:
A. "Report bleeding that saturates the client's dressing.": Excessive or saturating bleeding from a postoperative abdominal incision may indicate hemorrhage or disruption of the surgical site and requires immediate provider notification.
B. "Ensure the client's urinary output is no less than 20 mL per hour.": The expected minimum urinary output for an adult after surgery is at least 30 mL per hour, which reflects adequate renal perfusion and fluid balance. A urine output of 20 mL per hour is too low.
C. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected postoperatively and may signal urinary retention, a common complication due to anesthesia or opioids.
D. "Maintain the client in a supine position for 24 hours following surgery.": Keeping the client supine for 24 hours increases the risk of respiratory complications, including atelectasis and pneumonia. The nurse should encourage early ambulation and semi-Fowler’s positioning.
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