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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prop the feet up: Proping the feet up may not be effective in preventing plantar flexion contractures, as it does not provide sustained support to keep the feet in a neutral position. Plantar flexion can still occur with this position.
B. Apply an abduction pillow to the legs: An abduction pillow is used to keep the hips in a neutral position, not to prevent plantar flexion contractures. It is useful for preventing hip contractures but not specifically for the feet.
C. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip joint, not plantar flexion of the feet. It is used for positioning to prevent hip complications, but it does not address foot position or contracture prevention.
D. Use foot splints: Foot splints are designed to keep the feet in a neutral or dorsiflexed position, preventing the toes from pointing downward (plantar flexion). This is the most effective intervention to prevent plantar flexion contractures in an immobile client.
Correct Answer is B
Explanation
A. Silence: Silence alone is not necessarily indicative of a risk for violent behavior. While it can be a sign of withdrawal or anger, it does not directly suggest imminent violence.
B. Pacing: Pacing is a significant sign of agitation and restlessness, which can indicate an increased risk for violent behavior. When clients are unable to release tension through physical movement or if they are becoming increasingly agitated, pacing is a common manifestation.
C. Lack of eye contact: A lack of eye contact may be related to anxiety, shyness, or cultural factors. While it can indicate avoidance or discomfort, it is not a strong indicator of an impending violent outburst.
D. Lowered tone of voice: A lowered tone of voice often suggests calmness or control and is not typically associated with violent behavior. It is more likely to indicate de-escalation or subdued emotions.
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