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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Instructing the client's loved ones that the client should not have fresh flowers in their room (Choice A) is not a necessary action for rubella isolation. Rubella is transmitted through respiratory droplets, and the prohibition of fresh flowers is not a relevant precaution.
Choice B rationale:
Wearing a surgical mask when within 0.9 m (3 feet) of the client (Choice B) is the correct action. Rubella is an airborne disease, and wearing a surgical mask helps prevent the spread of infectious respiratory droplets to the nurse and other individuals.
Choice C rationale:
Placing the client in a room with negative-airflow pressure (Choice C) is not specifically indicated for rubella isolation. Negative-airflow pressure rooms are typically used for diseases that require strict airborne precautions, such as tuberculosis.
Choice D rationale:
Instructing the client that visitors will not be allowed while they are in isolation (Choice D) is not entirely accurate for rubella isolation. While isolation precautions are necessary, visitors can enter the room if they are properly protected, including wearing masks and following infection control protocols.
Correct Answer is D
Explanation
Choice A rationale: The client's present condition is the "Situation" component of SBAR. It identifies the immediate reason for the call and the current problem that requires the provider's attention or intervention.
Choice B rationale: Suggestions for the provider regarding client care constitute the "Recommendation" phase. This part involves the nurse proposing specific actions, tests, or treatments to address the identified clinical issue.
Choice C rationale: Physical findings are categorized under the "Assessment" portion of SBAR. This includes vital signs and clinical observations made by the nurse to evaluate the client's current physiological state.
Choice D rationale: Previous treatments belong in the "Background" section. This component provides historical context, including admitting diagnosis, medical history, allergies, and relevant interventions already performed to inform the provider.
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