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Question

Difficulty: MediumBasic Care and Comfort

A client who experienced a recent cerebrovascular accident has unilateral weakness. The nurse is assisting the client out of bed into a wheelchair for the first time. In which order should the nurse execute the following steps to safely perform a stand-and-pivot transfer? Arrange the actions from first to last.

  1. 1Position the wheelchair at a 45-degree angle on the client's unaffected side.
  2. 2Engage the wheel locks on both the bed and the wheelchair.
  3. 3Assist the client to sit on the edge of the bed and secure a transfer belt around their waist.
  4. 4Stand facing the client, grasp the transfer belt, and brace the client's weakened knee with your own knee.
  5. 5Instruct the client to bear weight on the strong leg while pivoting to reach back for the wheelchair armrests.

Answer

The correct sequence ensures safety by preparing the environment, securing the client, and executing the pivot on the client's strong side.
Following this precise chronological sequence minimizes the risk of falls and injury. The nurse must first establish environmental safety (positioning the chair on the strong side and locking wheels) before physically moving the client. Once the environment is secure, the nurse assists the client to sit, applies a safety device (transfer belt), and provides physical support (bracing the weak knee) before finally initiating the pivot maneuver.

Step-by-Step Solution

1
Position the wheelchair at a 45-degree angle on the client's unaffected side.
The destination equipment is properly positioned.
Setting up the environment first ensures the client can pivot toward their strong side with the shortest possible transfer distance.
2
Engage the wheel locks on both the bed and the wheelchair.
The bed and wheelchair are completely immobilized.
Immobilizing the equipment is a mandatory safety check to prevent the chair or bed from sliding away during the weight transfer.
3
Assist the client to sit on the edge of the bed and secure a transfer belt around their waist.
The client is sitting upright and equipped with a safety device.
Dangling allows the nurse to assess the client for orthostatic hypotension and dizziness, while the belt provides a secure hold for lifting.
4
Stand facing the client, grasp the transfer belt, and brace the client's weakened knee with your own knee.
Physical support and leverage are established.
Bracing the affected knee prevents it from buckling under the client's weight during the standing phase of the transfer.
5
Instruct the client to bear weight on the strong leg while pivoting to reach back for the wheelchair armrests.
The client safely transitions from a standing position into the wheelchair.
Reaching back provides a physical target and helps the client control their descent into the chair without falling.

Key Concept

Safe stand-and-pivot transfers for clients with unilateral weakness
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Topics

Basic Care and Comfort

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