Author Question: The physician has ordered ambulation for the 63-year-old client who has had surgery and has been in ... (Read 48 times)

luvbio · **on:** Jul 22, 2018

The physician has ordered ambulation for the 63-year-old client who has had surgery and has been in bed for three days. The nurse plans to do which of the following for this client?

1. Begin ambulation immediately after breakfast.
2. Pre-ambulation exercises
3. Obtain assistance with transfer of the client.
4. Perform passive ROM before ambulating.

Question 2

When measuring blood pressure, the nurse identifies the systolic blood pressure at the pressure when which of the following occurs?

1. Korotkoff's sounds develop a muffled whooshing quality.
2. The first of at least two tapping sounds are heard in phase 1.
3. The first sound is heard during phase 1.
4. A muffled blowing quality

olderstudent · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2
Rationale: Anticipating that the client's muscles will be weak, the nurse will plan to help the client perform pre-ambulation exercises to help regain strength in the muscles before attempting to walk the client. It would be best to wait an hour or two after meals to ambulate. Passive ROM will not help to strengthen muscles, although active ROM will be helpful. The nurse is not preparing to transfer the client, and will need to determine if assistance is required by the client's pre-bedrest activity level.

Answer to Question 2

2
Rationale: The nurse listens for at least two consecutive tapping sounds to ensure that they are not extraneous sounds, and then labels the first sound as the systolic blood pressure. A muffled whooshing sound is heard in phase 2, while a muffled blowing quality develops in phase 4.