The charge nurse is observing a newly hired nurse assess the client’s ability to ambulate while transferring from a supine position in bed. Which of the following actions by the newly hired nurse requires intervention?

A	Assisting the client to sit upright with legs dependent on side of bed for 10 seconds 
B	Assessing for upper and lower extremity weakness prior to standing by the side of the bed
C	Assisting the client to stand by the side of the bed for at least 1 minute
D	Assessing the client for dizziness or a sudden increase in heart rate prior to ambulation

UPDATE📣📣📣
Correct Answer is A. 
Rationale: When assisting clients to transfer from a supine position to ambulate, clients should be moved slowly and closely monitored for orthostatic hypotension and any weakness. It requires intervention if the nurse has the client sit and dangle the legs for 10 seconds. Clients should sit at the side of the bed for at least 1 minute for assessment of possible dizziness or vital sign changes. It is correct for the nurse to assess for extremity weakness prior to attempting to stand, assisting the client to stand for at least 1 minute prior to ambulation, and to assess the client for dizziness.