HESI Registered Nurse EXIT Practice Exam

What is an appropriate instruction for a UAP assisting a client post-surgery to ambulate for the first time?

1. Have the client sit on the side of the bed for at least 2 minutes before assisting.

2. If the client feels dizzy, advise them to take deep breaths.

3. Assist the client to the bathroom at least twice during the shift.

4. Let me know how the client feels after sitting in the chair.

The correct answer is: Have the client sit on the side of the bed for at least 2 minutes before assisting.

Having the client sit on the side of the bed for at least 2 minutes before ambulation is an important safety measure after surgery. This practice helps the client to gradually acclimate to an upright position, allowing their body to adjust to the change in posture. It is especially crucial post-surgically, as patients may experience dizziness, orthostatic hypotension, or weakness due to anesthesia or medication effects. By sitting on the edge of the bed, the client can gain stability and assess their tolerance for sitting upright before attempting to stand and walk, minimizing the risk of falls or injury during the first ambulation. The other options, while relevant to patient care, do not focus directly on the immediate needs of the client preparing for ambulation. For example, advising a client to take deep breaths if they feel dizzy can be helpful but does not proactively address the risk of becoming dizzy in the first place. Assisting the client to the bathroom at least twice is also not a priority instruction for their first ambulation, as this may happen too soon without assessing how the client feels. Finally, waiting for feedback about how the client feels after sitting in a chair does not guide immediate action to support their safe ambulation.