A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

Choice B rationale:

Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.

Choice A rationale:

Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.

Choice C rationale:

Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.

Choice D rationale:

Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.

Choice A rationale:

Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.

Choice B rationale:

This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.

Choice C rationale:

This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.

Choice D rationale:

This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.