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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Free Nursing Study Resources

Correct Answer is C

Explanation

This will help determine if there is any residual urine left in the bladder after voiding.

Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.

Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.

Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.

A. Send the UAP to be educated on how to care for a foot ulcer. B. Advise the UAP to wear gloves when caring for the FP. C. Instruct the UAP to start with basic wound care precautions. D. Ask the UAP which action they would take first and state why.

Correct Answer is A

Explanation

It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.

Choice B is not correct because advising the UAP to wear gloves when caring for the FP is not the first action the nurse should take.

Choice C is not correct because instructing the UAP to start with basic wound care precautions is not the first action the nurse should take.

Choice D is not correct because asking the UAP which action they would take first and stating why is not the first action the nurse should take.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments. What action should the nurse take first?

Correct Answer is A

Explanation

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago. Which intervention should the nurse implement next?

The nurse is teaching a client how to self-administer subcutaneous heparin injections. Which instruction should the nurse include?

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

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?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

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

While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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?