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 D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.
Correct Answer is B
Explanation
A. While a high-protein diet can support healing, it does not directly prevent the transmission of infection.
B. Performing hand hygiene before, during, and after direct contact with the client is crucial to prevent the transmission of pathogens and is a fundamental practice in infection control.
C. Positive-pressure airflow is used for clients who are immunocompromised to prevent them from contracting infections, not for clients with existing infections.
D. Changing bed linens daily can contribute to infection control but is not as effective as hand hygiene in preventing transmission.