A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Tell the client that the surgeon will prescribe restraints if they try to leave.

Explain to the client that they cannot leave until the surgeon discharges them.

Have the client sign an against medical advice form.

Administer a sedative medication to the client.

None

Answer and Explanation

The Correct Answer is C

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

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Correct Answer is D

Explanation

Beneficence is the ethical principle of doing good and acting in the best interest of the patient. By administering pain medication prior to turning the client, the nurse is reducing the client’s suffering and promoting their well-being.

Choice A. Autonomy is wrong because autonomy is the ethical principle of respecting the patient’s right to self-determination and decision-making. The nurse is not asking for the client’s consent or preference before giving pain medication or turning them.

Choice B. Fidelity is wrong because fidelity is the ethical principle of being faithful and loyal to the patient and honoring one’s commitments and promises. The nurse is not demonstrating fidelity by giving pain medication or turning the client.

Choice C. Veracity is wrong because veracity is the ethical principle of telling the truth and being honest with the patient. The nurse is not providing any information or education to the client before giving pain medication or turning them.

A. Interlock her fingers and hold her hands away from her body above her waist. B. Clasp her hands together in a relaxed position behind her body at her waist. C. Place one hand over the other against the part of the gown covering her upper body. D. Keep her arms at the sides of her body with her hands in a relaxed position.

Correct Answer is A

Explanation

The correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.

This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.

The nurse should also keep her hands above her waistline to prevent contamination

Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin

Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin

Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects

Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.

They are used to prevent and minimize infection during surgeries or invasive procedures

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Nursing Test Bank

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A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.
The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?