Body mechanics and safe transfers
Transfer questions reward technique that protects both client and nurse. Before moving anyone, assess their strength, weight-bearing status, cognition and cooperation, then decide whether help or a mechanical lift is needed. The safest answer in a stem describing a heavy, weak or unpredictable client is to obtain additional staff or a lift device, not to attempt the move alone with good technique.
The mechanics themselves are testable: widen the base of support, bend at the knees and hips rather than the waist, keep the load close to the body, tighten the abdominal and gluteal muscles, pivot the feet instead of twisting the spine, and push or pull rather than lift when possible. Raise the bed to waist height for care and lower it afterwards.
For a bed-to-chair transfer, place the chair on the client's strong side at a slight angle, lock the brakes on both bed and chair, lower the bed so the feet are flat on the floor, apply a gait belt, allow the client to dangle briefly to prevent orthostatic dizziness, and instruct them to push off the mattress rather than pull on the nurse's neck. Use a transfer board for clients who cannot bear weight, and a mechanical lift for those with no weight-bearing ability.
- •Assess weight-bearing status and cognition before every transfer
- •Gait belt around the waist, not the chest or under the arms
- •Chair on the client's strong side, brakes locked
- •Dangle first to prevent orthostatic hypotension
- •Pivot with the feet — never twist the spine
- •Get help or a lift rather than risking an unsafe solo transfer
Canes, walkers and crutches
A cane is held on the stronger side, with the handle at hip or greater trochanter level and the elbow flexed about fifteen to thirty degrees. The client advances the cane and the weaker leg together, then steps through with the stronger leg. On stairs, the stronger leg leads going up and the weaker leg leads going down, which candidates remember as up with the good, down with the bad.
A walker is positioned so the client's arms flex slightly at the elbows when gripping the handles. The client lifts or rolls the walker forward a comfortable distance, ensures all four points contact the floor, then steps in with the weaker leg followed by the stronger. Clients do not lean over the walker, do not pull themselves to standing using it, and never use a walker on stairs.
Crutch teaching includes weight borne on the hands and not the axillae — two to three finger widths of clearance prevents brachial plexus injury — and gait selection based on weight-bearing status. A four-point gait requires partial weight bearing on both legs and is slow but stable, a three-point gait suits one non-weight-bearing leg, and a two-point gait is faster with partial bearing on both. For stairs the same rule applies: strong leg first ascending, crutches and weak leg first descending. Rubber tips are checked for wear and floors kept clear of clutter and rugs.
| Device | Positioning rule | Stairs |
|---|---|---|
| Cane | Hold on strong side; advance with weak leg | Up with strong leg, down with weak leg |
| Walker | Elbows flexed 15–30 degrees; all points down before stepping | Not used on stairs |
| Crutches (3-point) | Weight on hands; 2–3 finger widths under axilla | Strong leg up, crutches and weak leg down |
| Gait belt | Around the waist, snug with room for a flat hand | Used for guarding during ambulation |
Complications of immobility
Immobility affects every body system, and the exam tests prevention rather than treatment. Cardiovascular effects include venous stasis with deep vein thrombosis risk and orthostatic hypotension; prevention involves early ambulation, ankle pumps, sequential compression devices, prescribed anticoagulation and gradual position changes. Respiratory effects include atelectasis and pneumonia; prevention is incentive spirometry, deep breathing and coughing, turning every two hours and adequate hydration.
Musculoskeletal deterioration includes muscle atrophy, contractures and disuse osteoporosis, prevented by range-of-motion exercises, functional positioning, splints and standing when possible. Integumentary risk is pressure injury, prevented by repositioning schedules, pressure-redistributing surfaces, moisture management and nutrition. Gastrointestinal effects include constipation, addressed with fluids, fibre and activity, while urinary stasis increases infection and calculi risk.
Psychosocial consequences are also examinable: sensory deprivation, depression and confusion, particularly in older adults. Interventions include orientation cues, social engagement, daylight exposure and involvement in self-care.
Fall risk assessment and prevention bundles
Fall risk is assessed on admission, after any change in condition and after any fall. High-risk features include age over sixty-five, a history of falls, altered mental status, impaired mobility or gait, visual impairment, urinary urgency or frequency, and medications such as sedatives, opioids, antihypertensives, diuretics and hypoglycaemics. Polypharmacy compounds each factor.
The prevention bundle is standard and appears repeatedly as correct answers: keep the bed in the lowest position with wheels locked, call light and personal items within reach, adequate lighting including night lighting, non-slip footwear, clear pathways, prompt response to call lights, scheduled toileting and hourly rounding, and appropriate use of bed or chair alarms. Physical restraints are not fall prevention; they increase injury risk and are used only as a last resort with an order and strict monitoring.
Delegation appears here too. Unlicensed assistive personnel may assist with ambulation and toileting, keep the environment clear and report changes, but the registered nurse performs the fall risk assessment and evaluates the client after a fall.
After a fall: the correct sequence
When a client is found on the floor, do not move them first. Assess responsiveness, airway, breathing and circulation, then check for injury including pain, deformity, head strike and neurological status. Take vital signs, ask what happened if the client can respond, and only then assist them back to bed with adequate staff and equipment. If head injury or anticoagulation is involved, neurological checks and provider notification are priorities.
Notify the provider and the family per policy, monitor with increased frequency for the next twenty-four hours, and reassess the fall risk plan to add interventions. Document objectively in the medical record: the findings, the assessment, the interventions and the client's response, using factual language such as found on the floor beside the bed rather than an assumption that the client fell.
An incident or occurrence report is completed for risk management, but it is never referenced or filed in the client's chart and no note states that a report was completed. That distinction is a frequently tested legal detail alongside the rule that documentation records observation, not blame.