The nurse is caring for a client who is 2 days postoperative from abdominal surgery. The nurse plans to have the client ambulate for the first time on this shift. Prior to getting the client up, the nurse:
1. Asks the client about readiness to walk.
2. Conducts a breathing assessment on the client.
3. Evaluates the client's level of pain.
4. Calls for a wheelchair to start the process.
3. Evaluates the client's level of pain.
Rationale:
Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
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