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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
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