Two days after surgery, a client experiences incisional pain while dangling at the bedside and refuses to ambulate as prescribed. The nurse establishes a problem of "Activity intolerance related to pain." Based on this problem, which outcome statement is best for the nurse to include in this client's plan of care?

Avoid pain-causing activity.

Ambulate without discomfort.

Show evidence of incision healing.

Take analgesics as prescribed.

Answer and Explanation

The Correct Answer is B

A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.

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Correct Answer is C

Explanation

A. A WBC count within the normal range does not indicate an adverse effect of gentamicin.
B. Gentamicin is more likely to increase BUN levels due to nephrotoxicity rather than decrease them.
C. Gentamicin is an aminoglycoside antibiotic known to cause ototoxicity, which can lead to hearing loss. Decreased hearing is a significant adverse effect that should be promptly addressed.
D. Photophobia is not a common side effect of gentamicin.

A. A Administer albuterol via nebulizer. B. Listen to the lungs fields. C. Measure urine output. D. Review serum potassium.

Correct Answer is B

Explanation

A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

Correct Answer is C

Explanation

A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Which client is at greatest risk for aspiration?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?