Question

the nurse has assisted the client to ambulate for the first time. after returning the client to bed, what is the nurses priority intervention?

• inform the client when ambulation is scheduled next.
• document the clients ambulation.
• discuss the clients feelings about the illness.
• assess the clients response to the ambulation.

Explanation:

Analyze the clinical scenario

The client has just ambulated for the first time. First-time ambulation carries risks of orthostatic hypotension, dizziness, fatigue, and changes in vital signs. The nurse must determine the immediate priority action upon returning the client to bed.

Apply the nursing process framework

Using the Nursing Process Priority framework, assessment is always the first step before planning, implementing, or documenting care.

Using the Assessment vs Evaluation knowledge point

• Assessment must occur immediately after an activity to determine how the client tolerated it.
• Assessing the client's physiological and subjective response (e.g., heart rate, respiratory rate, dizziness, pain) is critical to ensure safety.

Evaluate the options

• Inform the client when ambulation is scheduled next: This is a planning/teaching action, which is not the immediate priority.
• Document the client's ambulation: Documentation is important but must occur after the client's response is assessed and they are safe.
• Discuss the client's feelings about the illness: This addresses psychosocial needs, which is not the immediate physiological priority after physical exertion.
• Assess the client's response to the ambulation: This is the immediate priority assessment to ensure client safety and evaluate tolerance.

Answer:

• Inform the client when ambulation is scheduled next.
• Document the client's ambulation.
• Discuss the client's feelings about the illness.
• Assess the client's response to the ambulation. (Correct answer)