Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.