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 B

Explanation

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

A. A. A client who has a venous stasis ulcer. B. A client who has peripheral hematomas. C. A client who underwent a barium swallow study. D. A client who takes an iron supplement.

Correct Answer is C

Explanation

Correct answer: C

A. A client who has a venous stasis ulcer: This is less likely to cause a false positive result. While ulcers can bleed, the fecal occult blood test is designed to detect small amounts of blood in the stool, not necessarily blood from other sources like venous stasis ulcers.

B. A client who has peripheral hematomas: Peripheral hematomas are typically not related to the fecal occult blood test. They generally wouldn’t affect the results unless there was significant bleeding or if the hematomas were a result of an underlying bleeding disorder.

C. A client who underwent a barium swallow study: This is the most likely to cause a false positive result. Barium used in the study can sometimes appear as a false positive on the test due to its interference with the chemical reactions used to detect blood.

D. A client who takes an iron supplement: Iron supplements can actually cause a false negative result rather than a false positive because they may darken the stool and mask the presence of blood.

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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 assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse in a provider’s office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result?

Correct Answer is C

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?