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 ["A","B","C","D","E"]
No explanation
Correct Answer is A
Explanation
The correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.
This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.
The nurse should also keep her hands above her waistline to prevent contamination
Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin
Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin
Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects
Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.
They are used to prevent and minimize infection during surgeries or invasive procedures
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