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Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse and an unlicensed assistive personnel (UAP) are preparing to transfer a client with left-sided hemiparesis from the bed to a bedside chair. The client is on contact precautions for a methicillin-resistant *Staphylococcus aureus* (MRSA) wound infection. Which action by the nurse best demonstrates adherence to safety and injury prevention protocols?

  1. A
    Directing the UAP to independently evaluate the client's bilateral leg strength and balance prior to initiating the movement.
  2. B
    Applying soft wrist restraints temporarily during the movement to ensure the client does not reach for and dislodge their peripheral intravenous line.
  3. Securing a transfer belt around the client's waist and standing on the client's left side to provide physical support during the pivot.Answer
  4. D
    Removing the isolation gown and gloves right before the physical transfer to prevent the personal protective equipment from impeding movement.

Answer

The nurse should secure a transfer belt around the client's waist and stand on the client's left side to provide support during the transfer.
When transferring a client with hemiparesis, the nurse must stand on the client's weak or affected side (in this case, the left side) to provide adequate support and block the weak knee if it begins to buckle. Using a transfer belt ensures a secure grip, reducing the risk of a fall or musculoskeletal injury.

Step-by-Step Solution

1
Analyze the client's physical deficits.
The client has left-sided hemiparesis, meaning the left side is weak and prone to buckling.
Identifying the side of weakness dictates where the nurse must stand to provide adequate physical bracing.
2
Evaluate the infection control requirements.
The client requires contact precautions, meaning a gown and gloves must be worn during all physical contact.
Adhering to transmission-based precautions prevents the spread of healthcare-associated pathogens.
3
Assess the delegation and restraint constraints.
Physical assessments cannot be delegated to a UAP, and restraints cannot be used for temporary staff convenience.
Following legal and ethical guidelines ensures client safety and rights are maintained.
4
Select the safest nursing action.
Using a transfer belt and standing on the affected (left) side provides maximum safety without violating protocols.
This intervention directly minimizes the risk of a fall or injury during mobility.

Key Concept

Safe Client Transfer and Environmental Safety Protocols
Estimated Time:1m 0s
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Topics

Accident, Error, and Injury Prevention

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