A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's height

The client's ability to communicate

The client's current weight-bearing status

The type of equipment used in previous transfers

Answer and Explanation

The Correct Answer is C

A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.

B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.

C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.

D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.

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Correct Answer is A

Explanation

A. Washing the area of the puncture thoroughly with soap and water is the first and most immediate action to reduce the risk of infection and transmission of bloodborne pathogens. This should be done as soon as possible after the injury.

B. Going to employee health services is necessary but should follow immediate first aid measures.

C. Completing an incident report is important for documentation and accountability but is not the immediate priority after a needle-stick injury.

D. Reporting the incident to the charge nurse is necessary for proper protocol but does not take precedence over ensuring the injury is properly cleaned first.

A. Perform range-of-motion (ROM) exercises at least two to three times daily. B. Auscultate breath sounds at least every 2 hr. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply anti-embolic stockings.

Correct Answer is B

Explanation

A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.

B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.

C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.

D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.

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A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

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