A one-day post-operative client complains of having a lot of mucus in his throat and is having a difficult time moving it to his mouth so he can spit it out. The client is reluctant to perform coughing and deep breathing due to pain. Based on the data, the priority problem that the nurse could assign to this patient is:

activity intolerance.

ineffective breathing pattern.

ineffective gas exchange.

ineffective airway clearance.

Answer and Explanation

The Correct Answer is D

D. This refers to the inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. Based on the client's complaint of difficulty moving mucus from the throat to the mouth for expectoration, ineffective airway clearance is the priority problem. The client's reluctance to cough and deep breathe due to pain further exacerbates this issue, as effective airway clearance is crucial for preventing complications such as respiratory infections or atelectasis post-operatively.

A. Activity intolerance refers to insufficient physiological or psychological energy to endure or complete required or desired daily activities. In the case of a one-day post-operative client experiencing difficulty clearing mucus, activity intolerance is not the priority problem. The client's main issue is related to respiratory function and airway clearance rather than overall activity tolerance.

B. This refers to abnormal respiratory rate, depth, or rhythm that does not provide adequate ventilation. While the client's complaint of difficulty moving mucus and reluctance to cough or deep breathe suggests some respiratory discomfort, the main issue appears to be the inability to effectively clear airway secretions rather than an overall ineffective breathing pattern.

C. This refers to the inability to exchange oxygen and carbon dioxide across the alveolar-capillary membranes. While mucus in the throat can potentially affect gas exchange if it obstructs airflow significantly, the client's primary complaint is about difficulty clearing mucus rather than signs and symptoms of inadequate oxygenation or ventilation.

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Correct Answer is ["A","D"]

Explanation

A. Overweight or obesity is a modifiable risk factor. It can be addressed through lifestyle changes such as diet modification, increased physical activity, and behavioral interventions aimed at weight loss.

D. Smoking is a modifiable risk factor. It is within an individual's control to quit smoking, which can significantly reduce the risk of various health problems, including cancer.

B. A history of prostate cancer is not a modifiable risk factor. Once a person has had prostate cancer, it cannot be changed through lifestyle modifications or interventions.

C. Being male is a non-modifiable risk factor for prostate cancer. Gender is determined biologically and cannot be changed.

E. Age is a non-modifiable risk factor. As individuals age, they are naturally at higher risk for certain health conditions, including prostate cancer. Age cannot be changed through interventions.

A. Intractable B. Radiating C. Phantom D. Referred

Correct Answer is C

Explanation

A. Intractable pain refers to pain that is severe and persistent, difficult to control or manage despite treatment. It may be constant or intermittent but is generally not specific to a body part that has been amputated. Intractable pain is not typically used to describe pain specifically related to a phantom limb or residual limb pain after amputation.

B. Radiating pain is pain that spreads from its origin to another location in the body. It often follows the path of a nerve and can be associated with nerve compression or irritation. While radiating pain can occur in various conditions, it does not specifically describe the type of pain experienced in an amputated limb.

C. Phantom pain is perceived pain that feels like it is coming from a part of the body that has been amputated. It is a common phenomenon after limb amputation where the brain continues to receive pain signals from nerves that originally innervated the missing limb. Phantom pain is the correct term for the pain experienced by a client with a below-the-knee amputation who complains of pain in the right ankle. It is described as constant pain in the missing limb or part.

D. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin. It occurs because of shared neural pathways between different areas of the body. Referred pain is not typically used to describe pain specifically related to amputation or phantom limb pain.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a 74-year-old male client. The client has a family history of prostate cancer, is 50 pounds overweight and history of smoking tobacco X 60 years. Which of the following are modifiable risk factors for this client's health? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D"]

Explanation

A client who has had a right-sided below-the-knee amputation is complaining of constant pain in his right ankle. The nurse documents that the client is experiencing what type of pain?

Correct Answer is C

Explanation

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

The nurse explains to the client that intravenous fluid administration is used to:

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