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?

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.

The correct answer is choice C, D, and E.

Choice A rationale:A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale:A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale:A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale:A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale:A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.