Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he 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 his care plan?

To ambulate without discomfort.

To take analgesics as prescribed.

To show evidence of incision healing.

To avoid pain-causing activity.

Answer and Explanation

The Correct Answer is A

The goal of the care plan should be to help the client overcome his activity intolerance related to pain.

This can be achieved by helping him to ambulate without discomfort.

Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.

Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.

Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.

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Correct Answer is D

Explanation

Requesting military records by phone without the patient’s consent would be a breach of confidentiality.

Choice A is incorrect because sharing the health history with a case manager who is involved in the patient’s care would not be a breach of confidentiality.

Choice B is incorrect because discussing diagnoses with a physical therapist who is involved in the patient’s care would not be a breach of confidentiality.

Choice C is incorrect because providing a list of food allergies to nutritional services who are involved in the patient’s care would not be a breach of confidentiality.

A. Change coccyx dressing after performing routine care. B. Change coccyx dressing before performing routine care. C. Restate the vital importance of performing hand hygiene. D. Perform coccyx dressing change in the nursing station.

Correct Answer is C

Explanation

Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.

Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.

Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.

Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions. Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?

Correct Answer is D

Explanation

A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections. Which intervention is most appropriate to prevent the spread of MRSA to others?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which of the following is most useful for the nurse to include?

The nurse is caring for a patient one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

A client arrives at the emergency department (ED) with severe right upper quadrant pain. To assess the quality of the client's pain, which approach should the nurse use?