A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

Choice A rationale Rocking the client to a standing position is an implementation step used during the actual transfer process. However, this should only occur after the nurse has ensured the client is physiologically stable enough to tolerate the change in position. Moving directly to this step without checking for hemodynamic stability could lead to a fall if the client experiences sudden dizziness. Safety protocols require assessment of vital signs and physical readiness before any manual handling or movement. Choice B rationale Applying a gait belt is a critical safety intervention that provides the nurse with a secure point of contact to assist with the client's balance and stability. While it is a necessary part of the transfer process, it is not the very next step after securing the environment. The nurse must first determine if the client can safely transition from a supine to a sitting position without experiencing adverse physiological symptoms that would make the transfer unsafe. Choice C rationale Pivoting on the foot farthest from the chair is a specific technical maneuver used to align the body correctly during the transfer to prevent musculoskeletal strain for both the nurse and the client. This action occurs at the end of the transfer sequence. Before reaching this point, the nurse must have already assessed the client's ability to stand and ensured that the client's blood pressure has stabilized following the change in their physical orientation. Choice D rationale Assessing for orthostatic hypotension is the priority next step because changing positions from supine to sitting or standing can cause a rapid drop in blood pressure. This drop occurs due to the gravitational pooling of blood in the lower extremities, which can lead to cerebral hypoperfusion and syncope. Identifying a decrease in systolic pressure ≥ 20 mmHg or diastolic pressure ≥ 10 mmHg is vital to prevent falls and ensure the client's safety during the transfer.