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 B

Explanation

A. Insulin glargine is a long-acting insulin, and its dose is not based on before-meal blood sugar readings.
B. The client needs to be taught how to self-administer insulin glargine, as it is given subcutaneously once daily, usually at the same time each day.
C. Increasing the dosage in response to ketoacidosis is inappropriate; emergency treatment is required for this condition.
D. Insulin glargine does not have a role in treating severe hypoglycemia; fast-acting glucose or glucagon is used for such situations.

A. Clamp the catheter for 30 minutes prior to irrigating. B. Slowly irrigate catheter with saline using an infusion pump. C. Use a sterile syringe to irrigate with 20 mL normal saline. D. Power flush with 60 mL to remove mucous obstructions.

Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is C

Explanation

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?