A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity tolerance?
a. Vital signs before, during, and after activity
b. Body image and self-care abilities
c. Ability to use assistive or adaptive devices
d. Client's electrocardiography readings
ANS: A
To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the client's activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting.
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