While the nurse attempts to transfer the client to a standing position, the client cannot get off the bed. Which is the best intervention for the nurse to implement?
1. Return client to safety and reassess for weakness.
2. Secure the client and obtain a second transfer belt.
3. Speak clearly to client while standing face to face.
4. Change the plan of care to include a mechanical lift.
1
1. The best intervention for the nurse is to return the client to a safe position and reassess for weakness because this action decreases the risk for client injury and frees the nurse to evaluate the problem. The nurse should assess the client's fatigue, pain and discomfort, muscle strength, understanding of the client's role in standing, and willingness to participate. With the data the nurse gathers, the nurse organizes the data, draws conclusions, and plans care.
2. The nurse determines that the transfer belt is the reason for the unsuccessful trans-fer, eliminating the opportunity to gather additional information and increase the chance of successfully resolving the problem.
3. If the nurse reassesses the situation, the nurse uncovers communication difficulties; however, this may not be the problem and the nurse's action may decrease the client's self-esteem as the nurse assumes the client is hearing impaired or lacks understanding.
4. Changing the plan to a mechanical lift is premature.
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