A nurse is assisting a client who is 4 hr postoperative with getting 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?

"Why don't you want to be touched?"

"Would you like some pain medication before getting out of bed?"

"I will stand next to you and help if you need me to."

"We can talk about this after you have gotten out of bed."

Answer and Explanation

The Correct Answer is C

A. "Why don't you want to be touched?": Asking "Why" can make a client feel defensive and is considered non-therapeutic communication.

B. "Would you like some pain medication before getting out of bed?": This ignores the client's immediate assertion of independence and safety risk.

C. "I will stand next to you and help if you need me to.":. This response respects the client's autonomy while ensuring safety by maintaining proximity in case the client becomes unsteady.

D. "We can talk about this after you have gotten out of bed.": This dismisses the client's immediate concern and the potential risk of a fall.

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Correct Answer is A,C,B,D

Explanation

A. Verify the tube placement.: The nurse must always ensure the tube is in the stomach (via pH testing or X-ray) before putting anything down it to prevent aspiration.

C. Check the client's gastric residual.: This determines if the client is tolerating current feedings and ensures the stomach isn't too full to receive medication.

B. Pour the medication into the syringe and allow it to flow by gravity.: This is the actual administration step.

D. Clamp the NG tube for 20 to 30 min.: Since the tube was on suction, it must remain clamped after administration to allow the medication to be absorbed rather than sucked back out.

A. Inform the client they have the right to refuse treatment. B. Explain that the treatment is both safe and therapeutic. C. Notify the client's loved ones of the client's refusal of the procedure. D. Tell the client that the procedure is necessary.

Correct Answer is A

Explanation

A. Inform the client they have the right to refuse treatment.: The nurse’s primary responsibility is to support client autonomy. Under the Patient Self-Determination Act, any competent adult has the legal right to refuse treatment at any time.

B. Explain that the treatment is both safe and therapeutic.: This is a form of persuasion that disregards the client's stated wishes and can be seen as coercive.

C. Notify the client's loved ones loved ones of the client's refusal of the procedure.: This violates client confidentiality (HIPAA) and does not address the client's right to refuse.

D. Tell the client that the procedure is necessary.: This is a non-therapeutic response that dismisses the client’s concerns and pressures them into compliance.

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A nurse is assisting a client who is 4 hr postoperative with getting 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 administering a liquid medication to a client who has an NG tube set to intermittent suction. Identify the sequence of steps the nurse should take when administering the medication. (Move the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A,C,B,D

Explanation

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Correct Answer is A

Explanation

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