Difficulty: Medium
Average Score: 78%
Simulated
Passage / Scenario
A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair.After securing a safe environment, what should the nurse do next?
Correct answer
C
Rationale
The correct answer is C: Assess the patient for orthostatic hypotension. This is important to prevent falls and other complications when transitioning the patient to a standing position. Orthostatic hypotension can cause dizziness and fainting upon standing, so assessing for this condition helps the nurse determine the patient's readiness to stand safely. Rocking the patient up to a standing position (A) can increase the risk of falls. Pivoting on the foot farthest from the chair (B) is a technique used during the transfer process but is not the immediate next step after securing a safe environment. Applying a gait belt (D) is important for assisting with ambulation but should come after ensuring the patient can safely stand.