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Question

Difficulty: EasyBasic Care and Comfort

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a wheelchair. Arrange the following nursing actions in the correct sequence to ensure a safe transfer.

  1. 1Position the wheelchair on the client's strong (left) side at a 45-degree angle to the bed and lock the brakes.
  2. 2Assist the client to sit on the edge of the bed and assess for dizziness or orthostatic hypotension.
  3. 3Apply a transfer (gait) belt securely around the client's waist and ensure they are wearing non-slip footwear.
  4. 4Stand facing the client, grasp the transfer belt, and assist them to a standing position.
  5. 5Instruct the client to pivot on their strong leg and reach back for the wheelchair armrests before sitting.

Answer

The correct sequence is to first prepare the wheelchair on the strong side, then assist the client to sit on the edge of the bed, apply the transfer belt and footwear, help the client stand, and finally instruct them to pivot and sit in the wheelchair.
Safe transfer of a client with unilateral weakness requires a systematic approach prioritizing environmental safety, physiological readiness, and mechanical support. By placing the chair on the strong side first, the client can use their unaffected limbs to assist in the transfer. Dangling allows cardiovascular adjustment to prevent syncope. The transfer belt and footwear provide essential safety measures. Finally, pivoting on the strong leg and reaching for the armrests ensures a controlled descent into the wheelchair.

Step-by-Step Solution

1
Prepare the environment and wheelchair.
The wheelchair is locked and positioned correctly on the client's unaffected side.
Ensures the equipment is stable and positioned to maximize the client's use of their strong side.
2
Assist the client to a dangling position.
The client is safely sitting on the side of the bed.
Allows the nurse to assess for orthostatic hypotension and ensures the client has their balance before standing.
3
Apply the transfer belt and non-slip footwear.
The client is properly equipped for a safe weight-bearing transfer.
Provides a secure point of contact for the nurse and prevents the client from slipping on the floor.
4
Assist the client to a standing position.
The client is upright and bearing weight primarily on the strong leg.
Initiates the physical transfer toward the wheelchair while maintaining safety and control.
5
Instruct the client to pivot and reach for the armrests.
The client safely transitions into the wheelchair seat.
Reaching for the armrests provides stability and prevents the client from missing the chair or falling during the descent.

Key Concept

Safe Client Transfer and Mobility
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Topics

Basic Care and Comfort

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