The nurse is helping the patient to walk. Which of the following actions should the nurse take first?
a. Help the patient to sit at the side of the bed for one or two minutes.
b. Support the patient by using a gait belt.
c. Assess the patient's activity tolerance, strength, and balance.
d. Ask a second nurse to be nearby.
C
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A Assessing the patient is the first responsibility; then the nurse helps the patient to sit at the side of the bed, allowing him or her to rest for one or two minutes to reduce the risk of orthostatic hypotension.
B A gait belt is used to provide support for the patient. However, the initial responsibility is to evaluate the patient's ability to walk.
C The nurse assesses the patient's activity tolerance, strength, coordination, and balance as well as orientation, and determines if there are any signs of distress that might preclude attempts at ambulation.
D The priority is for the nurse to assess the patient's activity tolerance.
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