The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

Choice A reason: High Fowler’s position aids breathing in respiratory distress but is not universally indicated without context. It may strain the client’s back or increase fatigue if sustained. Keeping mucous membranes moist is a broader intervention, preventing complications like oral infections or discomfort, especially in dehydrated or oxygen-dependent clients, making it more appropriate.

Choice B reason: Reporting changes in urine color monitors renal or hydration status but is less immediate than maintaining mucous membranes. Dry membranes risk infection or discomfort, particularly in clients on oxygen or with reduced oral intake. Urine monitoring is secondary, as it reflects longer-term changes rather than addressing an urgent physiological need.

Choice C reason: Keeping mucous membranes moist prevents drying, which can lead to infections, discomfort, or impaired swallowing. This is critical for clients on oxygen, with reduced intake, or in dry environments. Moist membranes support airway protection and comfort, aligning with nursing priorities to maintain basic physiological functions and prevent complications.

Choice D reason: Recording daily weight tracks fluid status or nutritional changes but is less urgent than moist mucous membranes. Dry membranes pose immediate risks like infection or airway irritation, especially in vulnerable clients. Weight monitoring is a longitudinal assessment, secondary to addressing acute comfort and infection prevention needs.

Choice A reason: Monitoring heart rate to stay within a suggested range is correct, ensuring safe exercise intensity for older adults. This prevents overexertion, especially with cardiovascular conditions. The statement reflects understanding, as it aligns with evidence-based guidelines for safe exercise, requiring no further teaching on this point.

Choice B reason: Avoiding exercises that impact chronic conditions is overly restrictive and incorrect. Many chronic conditions, like arthritis or diabetes, benefit from tailored exercise to improve function and health. This statement suggests misunderstanding, requiring teaching to clarify that appropriate exercises can manage, not exacerbate, chronic conditions, per geriatric care guidelines.

Choice C reason: Focusing on balance exercises is appropriate for older adults to prevent falls, a major injury risk. This statement shows understanding, as balance training improves stability and safety. No further teaching is needed, as it aligns with evidence-based recommendations for exercise in aging populations to enhance mobility.

Choice D reason: Completing 30 minutes of exercise at least 3 times a week aligns with CDC guidelines for older adults, promoting cardiovascular health and strength. This statement reflects correct understanding of exercise frequency and duration, requiring no further teaching, as it supports safe, effective physical activity for health maintenance.