A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Explanation & Rationale
A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse. B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls. C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone. D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.