A nurse is preparing to transfer a client who is non-weight bearing from the bed to a chair with the aid of an assistive personnel. The client is cooperative and has upper body strength. Which of the following assistive devices should the nurse use when transferring the client?
Powered-standing assist lift
Draw sheet
Gait belt
Full body sling lift
The Correct Answer is A
A. Powered-standing assist lift: A powered-standing assist lift is appropriate for a cooperative client with upper body strength who is non-weight bearing. It allows the client to participate by supporting themselves with their arms while the device safely moves them from the bed to a chair without bearing weight on their lower extremities.
B. Draw sheet: A draw sheet is typically used for repositioning a client in bed, not for transferring them from bed to chair. It does not provide the mechanical support needed to lift and transfer a non-weight-bearing client safely.
C. Gait belt: A gait belt is useful for clients who can bear weight to some degree and require minimal assistance during transfers. Since this client is non-weight-bearing, a gait belt alone would not provide adequate support and could lead to injury.
D. Full body sling lift: A full body sling lift is used for clients who are non-weight bearing and lack the ability to assist in transfers. Since the client described here is cooperative and has upper body strength, a full sling would not be necessary and may restrict their participation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
- Hoarseness: Mild hoarseness is a common temporary effect after thyroid surgery due to irritation or swelling near the recurrent laryngeal nerve. While it needs monitoring, slight hoarseness alone is not necessarily a sign of a serious complication if it is not worsening or associated with airway compromise.
- Drainage: A moderate amount of serosanguineous drainage from the incision site is expected after surgery. Although the drainage should continue to be monitored for increase or color change, the amount described here is not immediately concerning for a postoperative complication.
- Sensation: The client reports tingling in the fingers, which suggests hypocalcemia due to accidental removal or damage to the parathyroid glands during surgery. Hypocalcemia is a serious complication of thyroidectomy that can progress to muscle cramps, tetany, and seizures if untreated.
- Vital signs: The client’s rising temperature, tachycardia, hypertension, and increased respiratory rate are concerning for a developing thyroid storm, a rare but life-threatening complication after thyroid surgery. These vital signs warrant immediate intervention to prevent rapid deterioration.
- Pain assessment: A pain score of 3 out of 10 is mild and expected following surgery. This level of discomfort is manageable and not indicative of a major complication, provided it does not rapidly escalate or localize severely around the surgical site.
Correct Answer is A
Explanation
A. Place the client in a room near the nurses' station: Clients with quadriplegia are at high risk for complications such as respiratory difficulties, pressure injuries, and autonomic dysreflexia. Placing them near the nurses’ station allows for closer monitoring and quicker response to any urgent needs.
B. Check on the client every 4 hr: Clients with quadriplegia require more frequent monitoring than every 4 hours. Regular repositioning, skin assessments, and prompt attention to needs must occur at much shorter intervals to prevent complications.
C. Place the call light within the client's reach: A client with quadriplegia typically has limited or no use of their upper extremities. Therefore, they would be unable to effectively use a standard call light and would need alternative methods, such as a specialized call device.
D. Place the client's glasses on the bedside table: If the client is unable to move their arms due to quadriplegia, placing glasses on the bedside table would not be useful. Necessary personal items should be made accessible through assistance or adaptive equipment.
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