A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
The client's height
The client's ability to communicate
The client's current weight-bearing status
The type of equipment used in previous transfers
The Correct Answer is C
A. Knowing the client's height can be helpful for ergonomic considerations, but it is not critical for the transfer process.
B. The client's ability to communicate is important for understanding their needs and preferences but does not directly impact the physical safety of the transfer.
C. The client's current weight-bearing status is crucial to determine the safest method of transfer. If the client cannot bear weight, additional assistance or equipment may be necessary to prevent falls or injury.
D. While knowing the type of equipment used in previous transfers can provide insight, it is secondary to understanding the client's current physical capabilities and needs.
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Correct Answer is ["B","E"]
Explanation
A. The provider's name is not an acceptable identifier for verifying the client; it does not confirm the identity of the patient receiving the medication.
B. A facility-assigned identification number is an acceptable identifier as it uniquely identifies the client within the healthcare system.
C. The facility room number is not reliable for identifying clients, as multiple clients can be in the same room or there could be room changes.
D. The partner's full name is not an appropriate identifier for the client; it does not confirm the identity of the patient.
E. The client's full name is an acceptable identifier as it is a primary method to verify the identity of the client before medication administration.
Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.