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
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
Correct Answer is B
Explanation
This means low sodium levels in the blood.
Sodium is an electrolyte that helps regulate fluid balance and nerve and muscle function.
Vomiting and diarrhea can cause dehydration and loss of sodium through fluids.
Normal sodium levels are between 135 to 145 millimole/Liter.
Choice A is wrong because hypermagnesemia means high magnesium levels in the blood.
Magnesium is another electrolyte that helps with nerve and muscle function, as well as blood pressure and blood sugar regulation.
Hypermagnesemia is rare and usually caused by kidney failure or excessive use of magnesium supplements or laxatives.
Normal magnesium levels are between 1.46 to 2.68 milligram/deciliter.
Choice C is wrong because hypocalcemia means low calcium levels in the blood.
Calcium is an electrolyte that helps with bone health, muscle contraction, blood clotting and nerve signaling.
Hypocalcemia can be caused by vitamin D deficiency, kidney disease, thyroid problems or certain medications.
Normal calcium levels are between 8.8 to 10.7 milligram/deciliter.
Choice D is wrong because hyperkalemia means high potassium levels in the blood.
Potassium is an electrolyte that helps with nerve and muscle function, especially the heart.
Hyperkalemia can be caused by kidney disease, diabetes, adrenal gland disorders or certain medications.
Normal potassium levels are between 3.6 to 5.5 millimole/Liter.
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