The day after surgery to replace a hip joint, the client states he is not ready to ambulate, and will consider it tomorrow. The nurse's initial action is to:
1. Explain the benefits of ambulation at this time to the client.
2. Ask the client why he is resistant to ambulating at this time.
3. Notify the surgeon of the client's noncompliance.
4. Document the client's refusal.
Explain the benefits of ambulation at this time to the client.
Rationale: Educating the client about the rationale for ambulation at this time is the initial intervention. It is premature to contact the health care provider. If the client continues to refuse to ambulate, his reasons for doing so should be discussed. Documentation of the exchange is needed, but should be done once the reason for the refusal is known.
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