Chapter 17: Safe Patient Handling

Multiple Choice

1. A patient’s physical mobility is impaired because of paralysis of both lower extremities. Which is the best method for the nurse to use to place the patient in semi-Fowler’s position?

a. Help the patient push up in bed by bending his or her knees.

b. Raise the head of the bed (HOB) to 45 degrees and pull the patient to it.

c. Roll the patient to one side using pillows to support his or her back.

d. Pull the patient to the (HOB) using a drawsheet and then raise the HOB.

ANS: D

With the assistance of another staff member and using a drawsheet, the nurse bends the patient’s knees to reposition the legs, pulls the patient to the HOB, elevates the HOB to 45 degrees, and removes wrinkles from the drawsheet. The patient is unable to push up because of paralysis. Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury. Rolling the patient to the side achieves Sims’ or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. “We will use a ceiling lift to get you out of bed.” b. “Several staff will logroll you to change position.” c. “You have to remain on your back until your spine is stable.” d. “Physical therapy will get you out of bed in the morning.”

2. The nurse is caring for a patient after a motor vehicle crash and instructs the patient to avoid turning independently because the spine is unstable. What explanation of bed mobility does the nurse provide the patient?

ANS: B

The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted. If the patient moves, he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain patient safety, the nursing staff turns the patient by logrolling and thereby keeps the head, neck, and spine in straight alignment, thus preventing bone fragments from shifting and potentially increasing the damage. The patient does not need a ceiling lift because he or she will not be getting out of bed until the spine is more stable. Remaining on the back will greatly increase the risk of pressure injury. Physical therapy may be tasked with getting the patient out of bed, but again until the spine is stabilized, the patient will not be getting out of bed.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Support the upper arm and leg with pillows. b. Move the patient away from the center toward a side of the bed. c. Elevate the patient’s head with two or three pillows. d. Wedge a pillow under the abdomen and chest.

3. The nurse and an assistant are moving a dependent patient from the supine to the lateral position. Which should the nurse implement to begin repositioning?

ANS: B

The nurse and assistant move the patient to one side of the bed to create space on the bed for turning and avoid dangling the patient’s arms and legs over the side of the bed. The nurse supports the upper arm and leg after the patient is turned. Usually one pillow under the head is suitable for the lateral position; two or three pillows hyperflex the patient’s head. If necessary, a pillow is wedged under the patient’s chest and hips to support the patient in the lateral position, allowing him or her to relax in this position.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Find an assistant to help move the patient to lateral position now. b. Express concern about the discomfort and encourage turning. c. Assess the patient’s need for pain medication before repositioning. d. Explain how important repositioning is for preventing pneumonia.

4. After 3 hours in the supine position, an older patient reports being stiff and too uncomfortable to move. Which intervention is most appropriate?

ANS: C

Lying motionless is common behavior for patients in pain. This older patient is likely to have thin, fragile skin and by not moving for 3 hours, has an increased risk of skin breakdown from tissue hypoxia. The nurse assesses the patient’s pain and determines a need for pain medication before attempting to reposition him or her. To preserve skin integrity and promote patient comfort, the nurse moves the patient to another position to facilitate the flow of oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene if necessary. Expressing concern about the pain does nothing to assess or treat the discomfort. Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Explain how the transfer of the patient will be done safely. b. Ask questions about how the patient usually transfers. c. Document that the patient declined help for the transfer. d. State that the health care provider ordered a transfer.

5. The patient with a hemiparesis is very hesitant to transfer from the bed to the chair. Which action does the nurse take first to accomplish the transfer?

ANS: B

By applying the nursing process, the nurse probes gently to gather information about the patient’s reluctance to transfer, including the methods used to complete other transfers, how many transfers have occurred, and events during the transfers that left the patient fearing or dreading further transfers. The nurse takes these data and plans nursing care in response. If the nurse assumes that the problem is fear, the patient’s true needs may not be met by even the most detailed explanation of safety measures. The first response should be to assess the problem and develop a plan of action. Refusal to transfer should be documented only if, after every effort to understand and address the patient concerns, the patient continues to refuse. By stating that the health care provider ordered a transfer, the nurse passes responsibility for transferring to the health care provider. This is unprofessional. The patient can feel coerced to transfer by the nurse’s implication that the patient has no choice; this is a legally tenuous position for the nurse to assume.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. “Place your arms around my neck to stand up.” b. “Bend both knees slightly when standing up.” c. “Hold the transfer belt for stability during transfer.” d. “Rock to help stand while pushing up with your hands.”

6. The nurse assists the patient with transferring from bed to chair by using a transfer belt. Which is the first instruction that the nurse gives to the patient after properly positioning him or her?

ANS: D

A rocking motion and pushing up with the hands moves the patient’s body in the direction of the transfer. The nurse is also rocking, and together they move as a unit. Having the patient hold the nurse around the neck increases the risk of injuring the nurse during a transfer. The nurse flexes at the knees and hips to lower his or her center of gravity; this is a more powerful force for transferring and decreasing the risk of back injury than standing upright and leaning toward the patient. The patient wears the transfer belt, and the nurse grabs the belt from underneath as the patient rocks forward. The nurse’s force on the belt and the nurse’s and patient’s weight shifting work as a unit to assist the patient to a standing position.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation 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.

7. 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?

ANS: A

The initial intervention for the nurse is to return the patient to a safe position. The nurse would then reassess for the cause of the weakness. 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.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Assure the patient that the lift is safe. b. Use two safety chains on a canvas sling. c. Delay the transfer until help is found. d. Double-check the wheel locks on the lift.

8. The nurse wants to transfer a patient from the bed to the chair by using a mechanical lift. The patient has difficulty following directions, and the nurse cannot find help. Which is the most important action for the nurse to implement?

ANS: C

To maneuver the patient safely with a mechanical lift, the nurse must find an assistant to help on the opposite side of the bed and help hold the chair as the nurse lowers the patient onto it. Whenever a patient has difficulty comprehending or following directions, additional help needs to be obtained. Reassuring the patient about the safety of the lift is appropriate but is less important than ensuring his or her safety on the lift. The chains attach to the sling, providing a strong bond between the lift and the sling, but they are not specifically designated as safety devices. Double-checking the wheel locks on the lift is important to patient safety, but the nurse should not even begin this transfer until an assistant is available.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Place the base of the lift under the side of the bed. b. Use the longer chains to support the patient’s torso. c. Ask the patient to hold the head up while in the sling. d. Instruct the patient to hold the chains during the transfer.

9. The nurse is teaching other caregivers about using a mechanical lift. What does the nurse include in the instructions focusing on patient safety?

ANS: A

The nurse ensures patient safety while transferring a patient with a mechanical lift by securing the base of the lift under the side of the bed. The base will also be set at its widest point for stability. The longer chain is used to support the patient’s legs. The patient lies in a supine position with the head relaxed on a small pillow if necessary. The nurse instructs the patient to cross the arms on the chest because the sling wraps around the patient very tightly, potentially resulting in injury.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Remove the sling from under the patient. b. Document patient response to the transfer. c. Secure the nurse call system within the patient’s reach. d. Return the base of the lift to its original position.

10. The nurse transfers the patient from the bed to the chair using a mechanical lift. Which should the nurse do before leaving the patient’s room to ensure patient safety?

ANS: C

To prevent patient injury from unnecessary reaching or attempts to get up, the nurse places the nurse call system close to the patient, makes sure that the patient can use the nurse call system, asks what the patient needs, and assesses the patient for safety before leaving the room. The sling remains under the patient while the patient is sitting in the chair as long as it does not increase the risk of skin breakdown or patient discomfort. With the sling in place, the nurse facilitates transferring the patient to the original position. The base may be left open and stored over the bed while the patient is in the chair. Once the patient is back in bed, the lift is returned to the original position and removed from the room.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Obtain a friction-reducing device and at least two other staff members. b. Instruct a nurse to stand at the head of the patient. c. Suspend the intravenous (IV) lines and Foley catheter from the stretcher. d. Wrap the patient in a sheet to prevent injury to the arms and legs.

11. A 225-pound (102-kg) patient is unconscious and needs to be transferred from the bed to the stretcher. Which action is most critical for the nurse to initiate before moving the patient?

ANS: A

The nurse effectively manages patient safety by using a friction-reducing device and at least three people to move a patient who is this weight. Suspending the Foley catheter from the stretcher is fine, but the IV lines must be hung from the stretcher for proper infusion. The patient must be observed closely during the transfer; wrapping the patient in a sheet obscures critical observations that can prevent accidents and injury to the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Place a pillow under both knees. b. Put a footboard against both feet. c. Insert a pillow under the flexed upper arm. d. Straighten the arms at the patient’s sides.

12. The nurse is preparing to place a patient in the Sim’s position. What action should the nurse take during the positioning?

ANS: C

The nurse places a small pillow under the patient’s flexed upper arm when the patient is in the Sim’s (semi-prone) position to maintain proper limb alignment. The knees are not elevated with a pillow in this position. If excessive pressure on the knees occurs, the entire anterior surface is padded to relieve the pressure, maintain normal body alignment, and prevent hyperextension at the knees. A footboard is used for patients in the supine position to prevent footdrop. The nurse flexes the patient’s arms and positions them at the shoulder level.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Increased pulse and increased respirations b. Decreased pulse and increased respirations c. Increased pulse and decreased respirations d. Decreased pulse and decreased respirations

13. While transferring a patient who has been bedridden for several weeks, the nurse notes that the patient becomes fatigued rapidly. What assessment data does the nurse expect to find to validate the patient’s changing status?

ANS: A

The patient’s body is responding to the increased workload on the heart and lungs and is manifested by elevations in both the pulse and respirations.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Ask the patient if this weakness has occurred before. b. Obtain a full set of vital signs after ambulating the patient. c. Encourage the patient to hold onto a staff member in the hall. d. Assess the patient for any potential cause of weakness or dizziness before ambulating. Assist patient in changing positions slowly.

14. A patient who is weak but motivated after surgery is going to ambulate for the first time. Which nursing intervention is most likely to facilitate patient safety?

ANS: D

To safely assist the patient in getting out of bed and ambulating for the first time postoperatively, the nurse assists the patient to change positions slowly and assesses the patient’s response to each change. The nurse would not need to assess for this weakness occurring in the past since it is related to surgery. Obtaining vital signs after ambulation will demonstrate patient tolerance but won’t promote safety during ambulation. Holding a staff member might injure both patient and staff if the patient falls; it would be safer to hold onto handrails or other assistive devices like a walker.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Determine the patient’s current pain level. b. Record the vital signs before ambulation. c. Position the gait belt around the patient. d. Assist the patient putting on socks.

15. The patient will be transferred to the chair an hour after receiving pain medication for the first time. Which activity is most important for the nurse delegate to nursing assistive personnel (NAP)?

ANS: C

The NAP will place the gait belt on the patient. Whenever there is doubt about a safe transfer, the transfer or gait belt should be used. The nurse determines the patient’s pain level because it requires nursing assessment and nursing judgment after medication is given. The nurse checks the vital signs because the patient just had medication for the first time and the nurse needs to evaluate the patient’s response. Socks, unless they have treads, afford little protection for ambulation. The priority for the NAP is patient safety, which includes applying the gait belt.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Carry the weight above the waist. b. Keep the patient close to the mover. c. Bend at the waist for heavy lifting. d. Tighten the stomach and back muscles.

16. The nurse is teaching a patient’s family how to maintain personal safety and prevent injury when lifting or moving the patient. Which concept does the nurse include in the instructions?

ANS: B

Decrease the force required to lift or move a patient by keeping the patient close to the person moving the patient. The mover provides a more stable base for moving a patient by keeping the patient close to the mover’s center of gravity; if the patient’s weight is higher than that of the mover, the mover becomes top heavy and more unstable and needs more force to move the patient. Bending at the waist increases the distance between the mover and the patient, making the mover’s foundation less stable and less powerful. This also increases the risk of injury. To move a significant weight without injury, the nurse tightens the abdominal and gluteal muscles in preparation for work.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Place the chair to the patient’s right side after sitting the patient on the edge of the bed. b. Place the chair to the patient’s left side after sitting the patient on the edge of the bed. c. Place the chair wherever the patient wants it after sitting the patient on the edge of the bed. d. Place the chair wherever it’s most convenient for the caregiver after sitting the patient on the edge of the bed.

17. The nurse teaches the caregiver to maintain the patient’s safety when transferring to a chair. Which teaching does the nurse include to address the weakness of the patient’s right side?

ANS: B

The nurse instructs the caregiver to place the chair on the patient’s strong side for safety and support.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. On the side of the stretcher b. At the head of the bed c. At the foot of the bed d. On the side of the bed without the stretcher

18. The patient’s nurse is directing staff who are moving a patient onto a stretcher with a slide board. Two nurses are positioned on the side of the stretcher. Where is the third nurse positioned?

ANS: D

Two nurses position themselves on the side of the stretcher while the third nurse positions self on the side of the bed without the stretcher.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Places the belt under the patient’s arms. b. Ensures the belt fits snugly. c. Holds the belt with palms facing upward. d. Rocks back and forth with patient before standing.

19. A nursing student is preparing to ambulate a patient using a transfer belt. Which action by the student requires intervention from the faculty member?

ANS: A

The transfer belt fits low across the waist. The other actions are correct.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation

Multiple Response

1. The charge nurse is orienting a new NAP about the steps of proper body mechanics. Which of the follow statements are correct steps? (Select all that apply.)

a. Avoid twisting.

b. Bend at the knees.

c. Tighten stomach muscles as you lift.

d. Straighten the legs.

e. Keep the weight close to the body.

ANS: A, B, E

You want to avoid twisting. You want to bend at the knees to maintain center of gravity and keep the trunk erect and the knees bent as you lift. Keep the weight close to your body. Do not straighten the legs. You tighten your stomach muscles before you lift.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Post hip fracture who has osteoarthritis b. Has a COPD exacerbation c. A patient who is paraplegic d. Suffered a stroke last week e. The patient with Alzheimer disease

2. Which of the following patients are at higher risk of complications from improper positioning? (Select all that apply.)

ANS: A, C, D, E

Patients with alterations in bone formation or joint mobility, impaired muscle development, and central nervous system (CNS) damage may experience motor impairment, proprioceptive loss, or cognitive dysfunction, all of which affect mobility.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Sensory status b. Temperature c. Upper arm strength d. Postural hypotension e. Cognitive status f. Pain level

3. The nurse is getting ready to transfer a patient from the bed to a chair for the first time after surgery. Which of the following are important to assess as factors in the transfer process? (Select all that apply.)

ANS: A, C, D, E, F

To provide for a safe transfer it is important to assess sensory status, including central and peripheral vision, adequacy of hearing, and presence of peripheral sensation loss. This will impact the ability of the patient to contribute to a safe transfer. Patients with visual and hearing losses need transfer techniques adapted to deficits. Immobile patients can have decreased muscle strength, tone, and mass, which affect the ability to bear weight or raise the body. Assess presence of weakness, dizziness, or orthostatic (postural) hypotension. Determine patient’s risk of fainting or falling during transfer. The move from a supine to a vertical position redistributes about 500 mL of blood; immobile patients may have decreased ability for the autonomic nervous system to equalize blood supply, resulting in orthostatic hypotension. Assess the patient’s cognitive status, including ability to follow verbal instructions. Assess the patient for pain (e.g., joint discomfort, muscle spasm) and measure level of pain using a scale from 0 to 10. Offer prescribed analgesic 30 minutes before transfer. Temperature does not affect the transfer process. However, if the patient had a fever, the nurse would address that prior to moving the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Stay with the patient. b. Notify the health care provider. c. Complete an occurrence report per agency policy. d. Evaluate the incident. e. Provide supportive care to the patient.

4. The nurse is transferring a patient and he or she sustains an injury during the transfer. What steps must the nurse take? (Select all that apply.)

ANS: A, B, C, D, E

If a patient sustains an injury during transfer it is important to:

Stay with patient and notify the health care provider immediately.

–Provide necessary supportive care until the patient is stable.

Evaluate incident that caused injury (e.g., assessment inadequate, change in patient status, improper use of equipment, insufficient number of caregivers to assist).

–Complete occurrence report according to agency policy.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Patient failed Sit and Shake: use sit-to-stand lift b. Patient failed Stretch and Point: assess patient’s weight-bearing ability c. Patient is reluctant to participate: ask patient about ability to stand d. Patient passes Stand: ask patient to march in place e. Patient passes Walk: assess for stability and safety awareness

5. A nurse has assessed several patients using the Banner Mobility Assessment Tool (BMAT). Which actions by the nurse are appropriate for the patient’s BMAT results? (Select all that apply.)

ANS: B, D, E

The BMAT tool is part of a mobility assessment. It includes Sit and Shake, Stretch and Point, Stand, and Walk. The patient who failed Stretch and Point needs an assessment of his or her ability to bear weight on at least one leg as the next step. Once the patient has demonstrated the ability to stand, the nurse instructs the patient to march in place and advance step. If the patient is successful with this, the nurse then assesses his or her stability and safety awareness. The patient who fails Sit and Shake will need a total lift. For safety, do not ever rely on self-report from the patient or family about the patient’s ability to sit, stand, and ambulate.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. The visitors involved in assisting the patient to transfer b. Home care instructions for the patient about transferring c. The patient’s blood pressure before and after each transfer d. A description of the patient’s response to each transfer e. Presence of NAP needed for transfer purposes

6. The nurse successfully transfers a patient from the bed to the chair and back. What information does the nurse to include in the progress notes? (Select all that apply.)

ANS: B, C, D, E

The nurse documents the patient’s response to each transfer in objective terms to record the events and subjective terms to relate the patient’s response to communicate information. Factors to consider in the documentation are breathing difficulties, dizziness, balance, muscle strength, patient complaints, type and degree of assistance the patient requires to transfer, and progress toward goals and outcomes. To prevent patient and visitor injuries, visitors should not assist the patient to transfer; however, the NAP can. Home care instructions are suitable before discharge and teaching should occur at each encounter. Patient blood pressure is recorded on the graphic flow or vital signs sheet and demonstrates stability or change in patient’s condition in response to the intervention.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Integrated Process: Communication and Documentation