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. "You can obtain a personal response system that will be activated if you fall.": A personal emergency response system allows the client to summon help immediately after a fall, promoting independence and safety for individuals living alone.
B. "You should contact a family member once a week to keep in touch.": Weekly contact provides emotional support but does not ensure timely assistance in the event of a fall. Regular communication is helpful, yet it does not directly reduce fall risk or guarantee safety if an emergency occurs.
C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Having a UAP visit daily may not be realistic or necessary, especially for independent seniors. This does not provide continuous supervision or an immediate response in case of a fall occurring outside scheduled visits.
D. "You need to move to a skilled nursing facility where they can prevent falls.": Suggesting relocation is premature and disregards the client’s desire for independence. Fall prevention strategies and assistive technology should be explored before recommending institutional care.
Correct Answer is A
Explanation
Rationale:
A. INR: The International Normalized Ratio (INR) is used to monitor the effectiveness and safety of warfarin therapy. It standardizes prothrombin time results, allowing clinicians to determine whether the client’s anticoagulation is within the therapeutic range to prevent clotting without causing excessive bleeding.
B. Factor VIII: Factor VIII is a clotting factor assessed in hemophilia or other coagulation disorders. It is not used to monitor warfarin therapy and does not indicate the therapeutic effect of anticoagulation.
C. Bleeding time: Bleeding time measures platelet function and vascular integrity, but it does not assess the anticoagulant effect of warfarin. It is unrelated to monitoring warfarin dosing.
D. aPTT: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin. It does not provide information about the client’s warfarin anticoagulation status.
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