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Difficulty: MediumBasic Care and Comfort

A client who is recovering from abdominal surgery is preparing to move from the bed to a bedside chair for the first time. In what sequence should the nurse perform the following actions to ensure a safe transfer? Arrange the steps in the correct chronological order.

  1. 1Position the bedside chair at a 45-degree angle to the bed and lock all wheels.
  2. 2Elevate the head of the bed to facilitate a seated posture.
  3. 3Assist the client to pivot their legs over the edge of the mattress to a dangling position.
  4. 4Monitor the client for any signs of dizziness or orthostatic hypotension.
  5. 5Secure a transfer belt around the client's waist before assisting them to stand.

Answer

The correct sequence begins with preparing the environment (placing and locking the chair), followed by elevating the head of the bed, assisting the client to dangle their legs, monitoring for dizziness, and finally applying a transfer belt before standing.
Safe client mobilization requires a systematic approach. The nurse must first secure the environment by locking the chair in the optimal position. Next, the client is brought upright gradually by elevating the head of the bed and then pivoting to a dangling position. This gradual movement is crucial for post-operative clients to prevent orthostatic hypotension. The nurse must then verify the client's stability by checking for dizziness before applying the gait belt and initiating the weight-bearing phase of the transfer.

Step-by-Step Solution

1
Prepare the environment and equipment.
The destination chair is positioned correctly and secured.
Ensuring the chair is locked and appropriately angled guarantees a safe landing point and prevents the equipment from rolling during the transfer.
2
Raise the head of the bed.
The client is moved into an initial upright position.
Elevating the head minimizes physical exertion for the client and protects the abdominal incision from excess strain while transitioning.
3
Assist the client to a dangling position on the edge of the bed.
The client's legs are dependent, allowing the cardiovascular system to adjust.
Gradual position changes are essential in post-operative care to prevent a sudden drop in blood pressure.
4
Evaluate the client for orthostatic changes.
The nurse confirms the client is stable enough to stand.
Dizziness or syncope can lead to severe injury if the client is allowed to bear weight while hemodynamically unstable.
5
Apply a gait belt and assist with the stand-and-pivot maneuver.
The client is safely moved into the chair.
A transfer belt provides the nurse with a firm, safe hold on the client's center of gravity without pulling on their arms or shoulders.

Key Concept

Safe Client Transfer and Mobility
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Topics

Basic Care and Comfort

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