While the nurse is attempting to transfer a patient to a standing position, the patient cannot get off the bed. Which is the initial intervention for the nurse to implement?
a. Return the patient to a safe position on the bed.
b. Put a second transfer belt on the patient.
c. Get additional personnel to help with the transfer.
d. Assess the patient for unknown weakness.
A
The initial intervention for the nurse is to return the patient to a safe position. This follows Mas-low's hierarchy of needs. The nurse would then reassess for weakness because this action de-creases the risk for patient injury and frees the nurse to evaluate the problem. The nurse should assess the patient's fatigue, pain and discomfort, muscle strength, understanding of the patient's role in standing, and willingness to participate. The nurse organizes the data that he or she gathers, draws conclusions, and plans care. Further assessment is indicated after the patient is safe.
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