A nurse is caring for a client who is 1 day postoperative following abdominal surgery. Which of the following client statements indicates a need for further instruction?
"I will get up and walk with the physical therapy aide."
"I will do leg exercises every hour while I am awake."
"I will take off my antiembolic stockings before I go to bed."
"I will use a footstool while I sit in a chair."
The Correct Answer is C
A. Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B. Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C. Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D. Using a footstool while sitting in a chair promotes proper positioning and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
Correct Answer is A
Explanation
A. Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare.
B. Referring the client to a counselor can be appropriate, but the primary response should be to support the client's decision.
C. Encouraging the client not to give up may not be appropriate if the client has made a well- considered decision to refuse further treatment.
D. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.
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