A nurse is assisting a client who is 4 hr postoperative to get out of bed.
The client states, “Do not touch me! I can get up by myself.” Which of the following responses should the nurse make?
“I think you need some pain medication before getting out of bed.”.
“We can talk about this after you have gotten out of bed.”.
“Why don’t you want to be touched?”.
“I will be next to you and will help if you need me to.”.
The Correct Answer is D
The correct answer is choice D. The nurse should respect the client’s autonomy and offer assistance if needed.
The nurse should also assess the client’s pain level and provide adequate pain relief before helping the client get out of bed.
Choice A is wrong because it implies that the client is in pain and needs medication, which may not be true.
The nurse should ask the client about their pain level and offer medication if appropriate.
Choice B is wrong because it dismisses the client’s feelings and does not address the underlying issue of why the client does not want to be touched.
Choice C is wrong because it may make the client feel defensive or interrogated.
The nurse should use open-ended questions and active listening to explore the client’s concerns and fears.
According to web sources, postoperative care involves monitoring and managing the client’s vital signs, pain, wound healing, fluid and electrolyte balance, bowel and bladder function, mobility, and psychological status.
The nurse should also educate the client about self-care, wound care, activity restrictions, medication use, signs of complications, and follow-up appointments.
The nurse should also provide emotional support and reassurance to the client and their family.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Correct answer: C
A. A client who has a venous stasis ulcer: This is less likely to cause a false positive result. While ulcers can bleed, the fecal occult blood test is designed to detect small amounts of blood in the stool, not necessarily blood from other sources like venous stasis ulcers.
B. A client who has peripheral hematomas: Peripheral hematomas are typically not related to the fecal occult blood test. They generally wouldn’t affect the results unless there was significant bleeding or if the hematomas were a result of an underlying bleeding disorder.
C. A client who underwent a barium swallow study: This is the most likely to cause a false positive result. Barium used in the study can sometimes appear as a false positive on the test due to its interference with the chemical reactions used to detect blood.
D. A client who takes an iron supplement: Iron supplements can actually cause a false negative result rather than a false positive because they may darken the stool and mask the presence of blood.
Correct Answer is D
Explanation
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today