The nurse transfers an assigned client from the wheelchair to the ...

[theo]

The nurse transfers an assigned client from the wheelchair to the hospital bed. Which items will the nurse include when documenting the client's response to the transfer?
 
  Select all that apply.
  1. Number of assistants needed
  2. Type of equipment used
  3. Pulse rate before and after the procedure
  4. Blood pressure before and after the procedure
  5. Safety precautions taken

Question 2

The nurse is documenting positioning for the client. Which piece of documentation is not required?
 
  1. Number of personnel required for turning and positioning
  2. Client's ability to assist with positioning
  3. Any signs of pressure areas or contractures
  4. Instructions provided to unlicensed assistive personnel (UAP)

[katheyjon]

Answer to Question 1

Correct Answer: 3,4

Although all of these items are required when documenting a client transfer, the only items that document the client's response to the transfer are the pulse rate and blood pressure. Comparing the vital signs before and after the transfer allows the nurse to assess how the client handled the transfer.

Answer to Question 2

Correct Answer: 4

The nurse would not document instructions provided to staff in the client's medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client's ability to assist with positioning is important documentation to track the client's progress. Pressure areas or contractures are important information to document.

[theo]

TYSM

[strudel15]

Thanks for the timely response, appreciate it