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

Explanation

A. Uses firm, circular motions to wash his hands: Friction is the most important component of handwashing because it physically loosens and removes microorganisms from the skin.

B. Washes his hands under hot running water: Hot water can cause dermatitis and increase skin irritation. Warm water is recommended to preserve skin integrity.

C. Scrubs hands with antibacterial soap for 10 seconds: The CDC and standard nursing practice recommend scrubbing for at least 20 seconds to effectively remove pathogens.

D. Dries his hands from the forearms to the fingers: Hands should be dried from the cleanest area (fingers) to the least clean area (forearms) to prevent re-contaminating the hands.

A. <img src="https://naxlex.com/nursing/assets/images/study_guides/Picture2A_1768379127.jpg" style="height:100px; width:430px" /> B. <img src="https://naxlex.com/nursing/assets/images/study_guides/Picture2_1768379127.jpg" style="height:124px; width:535px" />

Correct Answer is B

Explanation

A. Wheelchair on the left/affected side: In this image, the wheelchair is placed on the client's left side. This is incorrect because the wheelchair should be positioned on the client's unaffected (stronger) side to allow them to pivot and bear weight on their stable leg during the transfer.

B. Wheelchair on the right/unaffected side: This image shows the wheelchair placed on the client's right side. Since the surgery was on the left knee, the right leg is the stronger side. Placing the chair here allows the client to use their stronger limb to safely pivot into the wheelchair, minimizing the risk of falls or injury to the surgical site.

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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?

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Naxlex Comprehensive Predictor Exams

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