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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.

B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.

C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.

D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.

A. Encourage the client to include celery in their diet. B. Cleanse around the client's stoma with hydrogen peroxide. C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma. D. Empty the client's pouch when it is halfway full.

Correct Answer is D

Explanation

A. Encourage the client to include celery in their diet: Celery is high in fiber and stringy, which can increase the risk of obstruction in a client with a new ileostomy. Clients should avoid foods that can block the stoma until healing is complete and they are accustomed to managing their ostomy.

B. Cleanse around the client's stoma with hydrogen peroxide: Hydrogen peroxide can damage healthy skin and tissue around the stoma. The area should be cleansed gently with warm water and mild soap, avoiding harsh or irritating substances to promote skin integrity.

C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma: The skin barrier opening should be no more than 1/8 inch (about 0.3 cm) larger than the stoma. A larger opening exposes more skin to stoma output, increasing the risk for skin irritation and breakdown.

D. Empty the client's pouch when it is halfway full: Emptying the pouch when it is about halfway full prevents the weight from pulling on the seal, reducing the risk of leaks and protecting the skin. It also maintains client comfort and reduces the chance of pouch rupture.

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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?

Nursing Test Bank

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