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 D
Explanation
The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.
Choice A rationale:
Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.
Choice B rationale:
Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.
Choice C rationale:
Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.
Choice D rationale:
Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.
Correct Answer is D
Explanation
The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”
Choice A rationale:
Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.
Choice B rationale:
Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.
Choice C rationale:
Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.
Choice D rationale:
Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment
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