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.”.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.

The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.

The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.

Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.

Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.

Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.

Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).

Higher pressures may damage the wound tissue and increase the risk of infection.

Lower pressures may not be effective in removing debris and bacteria from the wound.

A. Deflate the cuff faster when repeating the BP measurement. B. Request a prescription for an antihypertensive medication. C. Use a narrower cuff to repeat the BP measurement. D. Measure the client’s BP in the other arm.

Correct Answer is D

Explanation

It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.

- The other options are not appropriate at this stage:

Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.

Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.

Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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?