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. Swab and shake bottle before administering the drops. B. Administer the drops with the head tilted upright. C. Lower the edge of the dropper into the canal of the ear. D. Keep the patient in supine position to administer the drops

Correct Answer is D

Explanation

The correct answer is choice D.

When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.

This position allows the medication to flow into the ear canal and reach the site of infection.

Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.

Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.

Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.

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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

The healthcare provider prescribes ear drops to an adult client with an ear infection. Which exacting should the nurse follow?

Correct Answer is D

Explanation

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

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 caring for a client who has only months predicted to live. The client avoids questions regarding plans for care. What is the next approach for the nurse to use when discussing end of life issues with the client?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL". How many tablespoons should the nurse instruct the client to take within each dose? (Enter numerical value only).

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

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

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?