A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

Have the client roll onto a transfer board and pull the board onto the stretcher.

Move the client onto the stretcher using a slide board with the assistance of two health care workers.

Apply a transfer belt to the client prior to transferring to the stretcher.

Move the client's upper body onto the stretcher first.

Answer and Explanation

The Correct Answer is B

A. Have the client roll onto a transfer board and pull the board onto the stretcher: Rolling the client onto a transfer board can be difficult and potentially dangerous, especially for an immobile client. It is safer to use a slide board with assistance to ensure the transfer.

B. Move the client onto the stretcher using a slide board with the assistance of two health care workers: A slide board, along with the assistance of two health care workers, ensures a safer and more controlled transfer of the immobile client, minimizes the risk of injury to both the client and the healthcare workers.

C. Apply a transfer belt to the client prior to transferring to the stretcher: A transfer belt is used for clients who are able to assist in the transfer, but it is not appropriate for immobile clients. Using a slide board with assistance is safer for transferring a client who is immobile.

D. Move the client's upper body onto the stretcher first: It is important to maintain a proper and safe method by transferring the entire body at once. Moving the upper body first could result in uneven weight distribution and increase the risk of injury during the transfer.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

A. Provide a mask for the client when they are outside their room: The client has a positive influenza test, it is important to prevent the spread of the virus to others by wearing a mask when outside their room to minimize the risk of transmission through respiratory droplets.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. While hand sanitizer is appropriate for influenza, droplet precautions, the client also has Clostridium difficile, which requires contact precautions, specifically hand hygiene with soap and water. Alcohol-based hand sanitizers are not effective against C. diff spores.

C. Don a gown when entering the client's room: The client is positive for C. difficile, which requires contact precautions. Wearing a gown when entering the room is necessary to protect healthcare workers from coming into contact with potentially contaminated surfaces or materials.

D. When removing personal protective equipment, remove gloves first: When removing personal protective equipment gloves should be removed first to avoid contamination of other surfaces. This is the recommended sequence for safe removal of PPE in contact precautions.

E. Place the client in a room with positive air flow: A room with positive air flow is necessary for airborne precautions (e.g., for tuberculosis or varicella), but it is not required for C. difficile or influenza, which are both managed through contact and droplet precautions.

A. Milk the chest tube at least three times a day B. Empty the drainage collection chamber when full C. Ensure intermittent bubbling is present in the water seal chamber D. Clamp the chest tube when transferring the client from bed to the chair

Correct Answer is C

Explanation

A. Milk the chest tube at least three times a day: Milking is generally not recommended as it can increase intrathoracic pressure and damage lung tissue. It should only be done with a provider’s order and specific indication.

B. Empty the drainage collection chamber when full: The collection chamber is a closed system and should not be emptied. When full, the entire drainage unit should be replaced to maintain sterility.

C. Ensure intermittent bubbling is present in the water seal chamber: Intermittent bubbling in the water seal chamber is expected during expiration or coughing, indicating air leaving the pleural space. However, continuous bubbling may suggest an air leak and requires evaluation.

D. Clamp the chest tube when transferring the client from bed to the chair: Clamping the tube is contraindicated during transport, as it can cause tension pneumothorax. The system should remain unclamped and below chest level.

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A nurse is preparing to transfer a client who is immobile and weighs 104.3 kg (230 lb) from the bed to a stretcher. Which of the following actions should the nurse plan to take?

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