Question

the nurse is caring for a client who has been on bed rest. the health care provider has just written a new order for the client to sit in the chair 3 times per day. which action will be most effective to transfer the client safely into the chair?

• positioning a friction-reducing sheet under the client
• infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair
• having the client sit on the side of the bed for several minutes before moving to the chair
• obtaining a quad cane for the client to use as a transfer aid

Explanation:

Analyze the clinical scenario

The client has been on prolonged bed rest. Prolonged bed rest leads to cardiovascular deconditioning, which puts the client at a high risk for orthostatic (postural) hypotension when transitioning to an upright position.

Evaluate the risk of orthostatic hypotension

Using the Patient Ambulation Safety knowledge point
When a client who has been on bed rest stands up or sits up too quickly, gravity causes blood to pool in the lower extremities. This pooling decreases venous return, cardiac output, and blood pressure, which can cause dizziness, lightheadedness, syncope, and falls.

Assess the interventions

• Option 1: Positioning a friction-reducing sheet is useful for lateral transfers in bed, but does not address the cardiovascular challenges of sitting up.
• Option 2: Infusing an intravenous fluid bolus is an invasive medical intervention that requires a specific provider order and is not a routine nursing action for standard mobilization.
• Option 3: Having the client sit on the side of the bed (dangling) allows the cardiovascular system to adjust to the positional change, preventing orthostatic hypotension and ensuring safety.
• Option 4: A quad cane is an assistive device for walking, not a primary tool for transferring a deconditioned bed-rest client safely into a chair.

Select the most effective action

Allowing the client to dangle their legs on the side of the bed for several minutes is the standard, most effective nursing intervention to prevent orthostatic hypotension and ensure a safe transfer.

Answer:

• positioning a friction-reducing sheet under the client
• infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair
• having the client sit on the side of the bed for several minutes before moving to the chair (Correct answer)
• obtaining a quad cane for the client to use as a transfer aid