The first day after surgery to repair a fractured hip sustained from a fall, an older adult client refuses to ambulate but states, "I will consider it tomorrow."
Which is the priority action by the nurse?
A) Coordinate personnel to assist with ambulation.
B) Document the client's refusal.
C) Assess why the client is refusing to ambulate.
D) Notify the healthcare provider.
Answer: C
The first thing the nurse should do is assess why the client is refusing to ambulate. The client might be fearful of falling, which had already occurred and resulted in a fractured hip. Once this is assessed, the nurse could plan interventions that would facilitate ambulation, such as controlling pain and reducing the fear of falling. It is premature to notify the healthcare provider. The nurse should not force the client to get out of bed. Documenting the client's refusal is appropriate, after determining the reason for the refusal.
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