A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Move the client using a slider board.

Use an air-assisted transfer device to move the client.

Raise the bed to 5 cm (2 in) above the level of the stretcher.

Position the head of the bed at 25° prior to the transfer.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

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Correct Answer is B

Explanation

Choice A rationale:

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

Choice B rationale:

Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.

Choice C rationale:

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Choice D rationale:

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

A. Establish the client's learning needs. B. Determine the client's literacy level. C. Evaluate the client's readiness for learning. D. Verify the client's computer access. E. Identify the client's learning style.

Correct Answer is A

Explanation

Choice A rationale:

Before initiating teaching for a client with a new diagnosis of type 2 diabetes mellitus, it is essential to identify the client's learning needs. This involves assessing what the client already knows about the condition, their level of understanding, and any specific areas of concern or interest. By establishing the learning needs, the nurse can tailor the teaching plan to address the client's individual requirements, thereby enhancing the effectiveness of the education provided.

Choice B rationale:

While determining the client's literacy level (Choice B) is important, it might not take precedence over understanding the client's learning needs. However, assessing literacy is still relevant because it helps the nurse adapt the teaching materials and language used to ensure the client comprehends the information.

Choice C rationale:

Evaluating the client's readiness for learning (Choice C) is significant, but it should ideally follow the identification of learning needs. Readiness for learning pertains to the client's emotional and psychological state, which can impact their ability to absorb new information. While essential, it should not be the initial step in planning teaching.

Choice D rationale:

Verifying the client's computer access (Choice D) is not directly related to the immediate planning of teaching for a new diagnosis of type 2 diabetes mellitus. While technology and access to online resources can enhance learning, this consideration is secondary to understanding the client's knowledge gaps and preferred learning style.

Choice E rationale:

Identifying the client's learning style (Choice E) is valuable in customizing the teaching approach, but it comes after establishing learning needs. Learning styles, such as visual, auditory, or kinesthetic, can influence the most effective way to present information. However, without first determining what the client needs to know, tailoring the teaching style might not yield optimal results.

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A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

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