Difficulty: Medium
Average Score: 72%
Full-length
A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
Correct answer
D
Rationale
Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.