The nurse assists the client with ambulation for the first time after surgery. Which nursing intervention is most likely to facilitate client participation in ambulation and ensure client safety?
1. Instruct the client to use the handrails.
2. Help client to apply well-fitting shoes.
3. Encourage client to hold onto the nurse.
4. Administer analgesia before ambulation.
1
1. The nurse instructs the client to use the handrails to increase client confidence and provide security during ambulation to prevent falls; with increased confidence, the client is more likely to participate in ambulation.
2. Well-fitting shoes are important to protect the client's feet and provide a nonskid surface to prevent falls. Lack of shoes can increase the client's reluctance to ambulate due to fear of injury or embarrassment.
3. The nurse does not encourage the client to hold onto the nurse because it increases the risk of the nurse's injury.
4. Administering pain medication before ambulation can increase the client's wil-lingness to participate in ambulation by increasing comfort; however, it potentially increases the client's risk for falls and injury if its administration is managed impro-perly because many medications, including analgesics, potentially cause orthostatic hypotension, dizziness, confusion, and other adverse effects potentially increasing the client's risk of falls and injury. If the client is too uncomfortable to ambulate without pain medication, the nurse should administer medication the client has had before this time, wait the proper amount of time to assess the effects of the drug, and assess the client's ability to safely ambulate before getting the client up to ambulate.
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