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 D
Explanation
The correct answer is choice D. “I’ll think about my grandfather’s farm to reduce pain.” This statement indicates an understanding of guided imagery, which is a relaxation technique that aims to help lower the levels of stress hormones and pain perception by imagining a scene that involves each of the senses and positive emotions.
Guided imagery can help to distract from pain signals and reduce anxiety, which can also contribute to pain.
Choice A is wrong because it does not involve creating a specific imagined reality, but rather noticing the sensation of muscle tension, which may increase awareness of pain.
Choice B is wrong because it does not involve using all of the senses and emotions, but rather listening to music, which may be relaxing but not as effective as guided imagery for pain relief.
Choice C is wrong because it does not involve imagining a scene, but rather using focused breathing to control pain, which is another relaxation technique but not guided imagery.
Correct Answer is C
Explanation
According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.
It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.
Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.
Choice A is wrong because chlorhexidine is not effective against C. difficile spores.
Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.
Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.
Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.
Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.
Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.