NCLEX-RN

Answer: B - The best action of the nurse is to inform the client about the dangers of immobility after an abdominal surgery. Blood clots may form in the legs which could travel with the blood and then cause circulatory and respiratory problems. Typically, physicians order ambulation on the same day of surgery or the 2^nd day post-op. The nurse should document the client’s refusal and notify the physician about this. The nurse should still encourage the patient to perform deep breathing exercises, turning or sitting on the bed. The legs should not be massaged to avoid dislodging blood clots.