Which of the following actions is a nurse preparing a client for ambulation?

Oct 12, 2025 4 min read •

senior care Patient Safety Nursing Practice

According to the CDC, millions of older adults fall each year, making pre-ambulation safety critical. Understanding which of the following actions is a nurse preparing a client for ambulation can help healthcare professionals and caregivers ensure a safe transition from bed to walking.

Quick Summary

The critical initial action is to assess the client's readiness by having them sit at the edge of the bed with their feet dangling to monitor for dizziness, a symptom of orthostatic hypotension.

Key Points

Dangling Feet is First: The initial preparatory action is having the client sit on the side of the bed with feet dangling for a few minutes to assess for dizziness or orthostatic hypotension.
Assessment is Paramount: A nurse must assess the client's ability, check physician's orders, and gather all necessary equipment before any movement.
Safety Equipment is Essential: Using a gait belt, ensuring proper non-skid footwear, and having assistive devices ready are critical safety measures.
Environment Must Be Clear: The nurse must remove all potential hazards from the path of ambulation, such as loose rugs or tangled IV lines.
Clear Communication is Key: Explaining the process and providing simple, clear instructions helps reduce client anxiety and improves cooperation.
Proper Body Mechanics Protects Both: Using correct body mechanics and standing on the client's weaker side ensures safety for both the nurse and the client during the ambulation process.

The Foundational Step: Assessing and Positioning the Client

Before any client begins to ambulate, especially older adults or those with a history of immobility, a nurse's primary action is a thorough assessment and careful positioning. The first and most critical step is assisting the client to a dangling position at the side of the bed. This involves having the client sit upright with their legs hanging over the side for several minutes. This action is essential for preventing orthostatic hypotension, a condition where a person's blood pressure drops significantly upon standing, causing dizziness, lightheadedness, or fainting.

Preparing the client for the dangle

Explain the process: The nurse should clearly explain what will happen and ask for the client's cooperation.
Raise the bed: Adjust the bed to a comfortable, safe height for the nurse to prevent back strain while helping the client sit up.
Support the client: Use proper body mechanics to assist the client in turning to their side, supporting their shoulders and legs as they move to a seated position.
Monitor for stability: The nurse should observe the client for any signs of unsteadiness, pallor, or dizziness during the dangling period. If these symptoms occur, the client should be gently returned to a lying position and reassessed later.

Environmental and Equipment Preparation

In parallel with the client assessment, the nurse must prepare the physical environment to ensure a safe path for ambulation. This includes gathering all necessary equipment and clearing any potential hazards.

Creating a safe environment

Check the pathway: Remove any obstacles, loose rugs, or spills from the intended ambulation route.
Secure medical devices: Ensure all IV lines, catheters, and drainage tubes are properly managed and not at risk of being tangled or dislodged.
Lock the bed and wheelchair: Before any movement, the nurse must ensure the brakes on the client's bed and any assistive devices, like a wheelchair, are securely locked.

Gathering necessary equipment

Proper footwear: Confirm the client is wearing appropriate, non-skid footwear. Socks alone are not considered safe.
Gait belt: Have a gait belt ready and properly applied to the client's waist. A gait belt provides a secure, firm grip for the nurse and added support for the client.
Assistive devices: Gather any prescribed assistive devices, such as a walker, cane, or crutches, and ensure they are within easy reach.

Patient-Specific Considerations

Preparing a client for ambulation is not a one-size-fits-all process. The nurse must tailor their approach based on the client's specific condition. The table below compares the preparation process for two different client profiles.


Action	Post-operative Patient	Older Adult with Chronic Weakness
Pre-Assessment	Review surgical report for weight-bearing restrictions; assess pain levels and administer medication if needed before moving.	Evaluate baseline mobility using tools like the Bedside Mobility Assessment Tool (BMAT). Assess cognitive function and balance carefully.
Dangling Time	May need a shorter dangle time, but vital signs are crucial due to recent anesthesia and blood loss. Monitor for at least 1-2 minutes.	Monitor for a longer period, 2-3 minutes, to account for potential cardiovascular and inner ear issues common in seniors.
Gait Belt Usage	Required for all initial ambulation to provide maximum stability and support due to incision pain and weakness.	Recommended based on assessment. Use to aid in transfers and provide a secure hold for fall prevention.
Assistive Device	Likely requires a walker for initial attempts to offload weight and ensure a wide base of support.	May use a cane, walker, or require two-person assist based on strength and balance deficits.
Pacing	Start with very short, frequent walks in the immediate post-operative period to prevent complications and build strength.	Ambulate slowly and deliberately, focusing on maintaining rhythm and balance rather than speed. Allow for frequent rest periods.

Proper Body Mechanics and Interventions

The nurse's body mechanics are just as important as the client's preparation. Poor technique can lead to injury for both parties. Always stand on the side of the client's weakness for optimal support. If the client begins to fall, do not attempt to stop the fall, but instead, guide them safely to the floor using the gait belt while protecting their head.

Conclusion

In summary, the preparation for ambulation is a comprehensive, multi-step process that places patient safety at its forefront. The sequence of actions—from initial assessment and proper positioning to environmental preparation and effective communication—is designed to mitigate risks like falls and injury. The first crucial action of dangling the client is key to testing for orthostatic hypotension. By following these protocols, nurses ensure a smooth and secure transition, promoting better outcomes and independence for their clients.

For more detailed information on proper nursing procedures for patient handling, refer to credible resources like the National Center for Biotechnology Information (NCBI) on nursing fundamentals.

Frequently Asked Questions

The most critical action is to assess the client's readiness by first having them sit with their feet dangling on the side of the bed. This helps check for orthostatic hypotension, which could cause dizziness and lead to a fall.

Dangling the feet allows the client's cardiovascular system to adjust to the upright position gradually. This prevents a sudden drop in blood pressure (orthostatic hypotension), which can cause dizziness, fainting, and falls, especially in patients who have been on bed rest.

A gait belt is a safety device that gives the nurse a secure and firm grip around the client's waist during transfers and ambulation. This provides stability, allows the nurse to help if the client loses balance, and reduces the risk of injury for both parties.

Signs a client is not ready include dizziness, lightheadedness, weakness, pain, or nausea after sitting upright. The nurse should also observe for unsteady balance, pallor, or other signs of distress.

No, a nurse should stand slightly behind and to the side of the client, typically on their weaker side. This positioning allows the nurse to support the client more effectively if they lose their balance.

Essential equipment includes a gait belt, appropriate non-skid footwear for the client, and any prescribed assistive devices such as a walker or cane. The nurse also needs to ensure a clear pathway free of obstacles.

Nurses can prevent injury by using proper body mechanics, which includes keeping their back straight, bending their knees, and lifting with their legs. They should also avoid pulling the client by their arms or neck and use a gait belt for a secure grip.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.