The client is getting up for the first time after a period of bed rest. Which of the following actions should the nurse take first?
a. Assess respiratory function.
b. Obtain a baseline blood pressure.
c. Assist the client to sit at the edge of the bed.
d. Ask the client if he or she feels light-headed.
B
When getting the client up for the first time after a period of bed rest, the nurse should document orthostatic changes. The nurse first obtains a baseline blood pressure.
Assessing the client's respiratory function is not the nurse's first intervention when getting a cli-ent up for the first time after prolonged bed rest.
After the nurse assesses the client's blood pressure, the nurse can assist the client to a sitting po-sition at the side of the bed.
After the client is in the sitting position at the side of the bed, the nurse should ask the client if he or she feels light-headed.
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