NCLEX-RNBasic Care and ComfortMedium
A nurse is caring for a client on the first postoperative day after abdominal surgery. Before assisting the client out of bed for the first time, which action is the priority?
- AAdminister the scheduled pain medication and wait 4 hours before ambulating
- BInstruct the client to perform 10 deep knee bends before standing
- CHave the client dangle at the edge of the bed for a few minutes before standing
- DAsk the client to stand up quickly to minimize discomfort during the transfer
Show answer & explanationAnswer & explanation
Correct answer: C. Have the client dangle at the edge of the bed for a few minutes before standing
Dangling the legs at the bedside allows the client's cardiovascular system to adjust to the upright position, reducing the risk of orthostatic hypotension and falls before standing. Standing quickly increases fall risk, waiting 4 hours delays needed mobility to prevent complications like DVT, and deep knee bends are inappropriate and unsafe post-op.
Why the other options are wrong
- A. Delaying ambulation increases risk of complications such as DVT and pneumonia.
- B. Deep knee bends are unsafe and inappropriate for a first postoperative transfer.
- D. Standing quickly increases risk of dizziness and falling.
Dangling Before Ambulation
Having a client sit at the edge of the bed with legs dangling before standing allows time for cardiovascular compensation, reducing orthostatic hypotension risk during first ambulation.
- Prevents sudden BP drop on standing
- Assess for dizziness before full standing
- Early ambulation prevents DVT, pneumonia, ileus
Memory trick: "Dangle before you dare to stand."