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:

Increased sensitivity to touch is not an expected physiological change associated with aging. Older adults often experience decreased sensitivity to touch due to changes in nerve endings and decreased skin elasticity. This can lead to decreased sensation rather than increased sensitivity.

Choice B rationale:

Decreased peripheral circulation is an expected physiological change associated with aging. With age, blood vessels can become less elastic and more narrow, leading to reduced blood flow to the extremities. This can result in cold extremities, delayed wound healing, and increased vulnerability to skin breakdown. Nurses should assess for signs of impaired circulation in older adult clients and provide appropriate interventions to prevent complications.

Choice C rationale:

Decreased airway resistance is not an expected physiological change associated with aging. Older adults often experience increased airway resistance due to changes in lung elasticity and chest wall compliance. This can lead to decreased lung function and a higher risk of respiratory issues such as pneumonia and bronchitis.

Choice D rationale:

Increased appetite is not an expected physiological change associated with aging. In fact, many older adults experience a decrease in appetite due to factors such as changes in metabolism, decreased sense of taste and smell, and underlying health conditions. This reduced appetite can contribute to malnutrition and weight loss in the elderly population.

A. "The nurse can adjust my mother's pain medication as needed.". B. "We are responsible for obtaining support services for our mother during this process.". C. "My mother would be able to live longer if we decide to use these services.". D. "The doctor will make all decisions about my mother's care.".

Correct Answer is B

Explanation

Choice A rationale:

The family member understanding that the nurse can adjust the mother's pain medication as needed indicates an understanding of the nurse's role in managing the patient's symptoms. However, this statement does not demonstrate an understanding of end-of-life care as a holistic process involving various aspects beyond pain management.

Choice B rationale:

This choice reflects a comprehensive understanding of end-of-life care. The family's responsibility to obtain support services shows awareness of the need for a multidisciplinary approach to address physical, emotional, and practical needs during this process. End-of-life care is a collaborative effort, and this choice accurately acknowledges the role of the family in coordinating necessary services.

Choice C rationale:

The statement about prolonging the patient's life through services reflects a misconception about end-of-life care. The focus of end-of-life care is on improving the quality of life and managing symptoms rather than attempting to extend life. This choice suggests a lack of understanding about the terminal nature of the illness.

Choice D rationale:

Believing that the doctor will make all decisions about the patient's care might indicate a lack of involvement or shared decision-making in the care process. End-of-life care often involves discussions among the medical team, patients, and their families to ensure that the patient's wishes and preferences are respected.

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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?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is B

Explanation

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