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

A well-approximated incision means that the edges of the wound are close together and aligned properly, which is a sign that the surgical incision is healing properly.

Choice A is incorrect because eschar and slough in the wound are not signs of proper healing.

Choice B is incorrect because beety red granulation tissue is not a sign of proper healing.

Choice C is incorrect because erythema and serosanguineous drainage are not signs of proper healing.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 80 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

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?

Correct Answer is B

Explanation

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse is inappropriate?

A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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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?