A patient is being assisted to the bathroom for the first time after Caeserean delivery. A recent experience caused a sudden fall made the client end up at the hospital. The options for the practical nurse (PN) are:

This comment by the practical nurse (PN) is likely to be the most helpful to the client. By offering to sit with the client, the PN shows empathy, support, and a willingness to provide companionship. This approach acknowledges the client's feelings of isolation and offers a listening ear. It provides an opportunity for the client to express his emotions, thoughts, or concerns if he wishes to do so. The presence of a caring and compassionate individual can help alleviate some of the client's feelings of loneliness and may encourage him to open up and engage in conversation or activities when he is ready.

A. "Come into the recreation area. We have your favorite card game and I will play it with you."
This choice assumes that engaging in a specific activity will automatically help the client and solve his current feelings of reclusiveness. While offering an activity may be beneficial in some cases, it is important to first address the client's emotional state and provide support before suggesting specific activities. Pushing the client to participate in an activity without acknowledging his current feelings may further alienate him and not address the underlying issues causing his reclusive behavior.
B. "Why do you want to stay in your room today?"
This choice may come across as confrontational or judgmental. Asking why the client wants to stay in his room implies that there is something wrong with his decision or that he needs to justify his behavior. This approach may make the client defensive or withdraw further. It is essential to create a safe and supportive environment where the client feels understood and validated, rather than questioning his choices.
C. "I know you are sad about not seeing your family as often, but they are visiting as much as they can."
While acknowledging the client's sadness about not seeing his family is important, dismissing his feelings by stating that his family is visiting as much as they can minimize or invalidate his emotions. It is crucial to provide empathy and validate the client's emotions without making assumptions or downplaying his experiences. This approach may not address the client's current state of reclusiveness or provide the support he needs.

The correct answer is: a. Paper tape, b. Small gauze pad, and d. Exam gloves.

Choice A: Paper tape

Reason: Paper tape is used to secure the gauze pad over the site after the saline lock is removed. It is gentle on the skin and helps to keep the gauze in place, preventing any bleeding or infection at the site.

Choice B: Small gauze pad

Reason: A small gauze pad is essential to apply pressure to the site after the saline lock is removed. This helps to stop any bleeding and provides a clean, sterile covering for the site.

Choice C: Sterile gloves

Reason: Sterile gloves are not necessary for this procedure. Exam gloves are sufficient to maintain cleanliness and prevent infection during the removal of the saline lock.

Choice D: Exam gloves

Reason: Exam gloves are used to maintain hygiene and prevent infection during the procedure. They provide adequate protection for both the nurse and the patient.

Choice E: Three mL syringe

Reason: A three mL syringe is not required for the removal of a saline lock. Syringes are typically used for flushing the saline lock, not for its removal.