The first day after surgery to repair a fractured hip sustained from a fall, an elderly client will not agree to ambulate but will consider it tomorrow. Which of the following should the nurse do first?
1. Assess why the client is refusing to ambulate
2. Notify the surgeon
3. Coordinate personnel to assist with ambulation anyway
4. Document the client's refusal
1. Assess why the client is refusing to ambulate
Rationale:
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 surgeon. The nurse should not force the client to get out of bed. Documenting the client's refusal to ambulate should be done after the reason for the refusal is known.
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