Two days after surgery, a client experiences incisional pain while dangling at the bedside and 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 this client's plan of care?

Avoid pain-causing activity.

Ambulate without discomfort.

Show evidence of incision healing.

Take analgesics as prescribed.

Answer and Explanation

The Correct Answer is B

A. Avoiding pain-causing activities would not address the problem of activity intolerance, nor would it promote recovery.
B. The goal is for the client to ambulate with minimal or no discomfort, which would indicate successful pain management and adherence to the postoperative plan.
C. Incision healing is important but does not directly relate to the problem of activity intolerance due to pain.
D. Taking analgesics as prescribed is a component of managing pain, but the outcome should focus on the result of this intervention, which is pain-free ambulation.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Allergic rhinitis is characterized by intranasal edema and swelling of the turbinates due to inflammation caused by allergens. This is a common physical finding in clients with allergic rhinitis.
B. Purulent secretions typically indicate an infection rather than an allergic condition.
C. Bilateral, pale gray nodules might suggest nasal polyps, which are associated with chronic sinusitis rather than acute allergic rhinitis.
D. Eye tearing is common in allergic rhinitis, but thick yellow nasal drainage suggests an infection rather than an allergic reaction.

A. Advise the client to see his healthcare provider for immediate evaluation. B. Encourage the client to keep checking the mole with a magnifying mirror. C. Ask the client if he often spends time outside in the sun without a shirt. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.
B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.
C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.
D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Correct Answer is A

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

Which client is at greatest risk for aspiration?

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Which intervention is most important for the nurse to implement when administering medications?