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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Develops fatigue when assisting with morning hygiene care

Needs assistance raising her legs to put on socks

Performs active range-of-motion (ROM) exercises of all extremities

Demonstrates mild dyspnea when eating breakfast

Answer and Explanation

The Correct Answer is C

A. Develops fatigue when assisting with morning hygiene care

Fatigue during hygiene suggests low endurance; not ready to ambulate safely.

B. Needs assistance raising her legs to put on socks

Needing assistance for simple tasks shows weakness and poor muscle control.

C. Performs active range-of-motion (ROM) exercises of all extremities

Performing full active ROM exercises indicates good muscle strength and coordination, suggesting readiness to attempt ambulation.

D. Demonstrates mild dyspnea when eating breakfast

Dyspnea with minimal activity (eating) indicates limited cardiopulmonary reserve-not yet fit to ambulate.

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Correct Answer is D

Explanation

A. Determining the client's mobility

Important for safety and fall prevention, but not the first priority during care planning.

B. Explaining the roles of the RN, licensed practical nurse, and assistive personnel

This is part of orientation and education but does not help in personalized care planning.

C. Introducing health care team members to the client

While courteous and important for building rapport, it’s not the first step in individualized care planning.

D. Understanding the client's routine for his own care at home

This helps in personalizing the care plan to maintain the client’s independence and preferences, especially for older adults in long-term care.

A. Ask the client if she has been out of bed today. B. Ask the client to push her legs and feet against the nurse's palms. C. Check the client's pedal pulses and feet for edema. D. Ask the client how strong she feels today.

Correct Answer is B

Explanation

A. Ask the client if she has been out of bed today:

This gives some insight into activity level but doesn't objectively measure strength.

B. Ask the client to push her legs and feet against the nurse's palms:

This provides a direct, physical assessment of the client's lower extremity strength, which is essential before ambulation.

C. Check the client's pedal pulses and feet for edema:

These assessments are related to circulation, not muscular strength.

D. Ask the client how strong she feels today:

This is subjective and may not reflect actual muscle strength or ability to ambulate safely.

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A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

Nursing Test Bank

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