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.

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Correct Answer is C

Explanation

A. A white blood cell count of 8,000/mm³ is within the normal range and does not indicate a need for dosage adjustment.
B. Inelastic skin turgor may indicate dehydration or aging but does not directly affect drug dosage.
C. Elevated serum creatinine levels indicate impaired renal function, which necessitates a reduced dosage of medications excreted through the kidneys, such as ticarcillin disodium.
D. Thin, fragile veins are a concern for intravenous access but do not affect the medication dosage.

A. Apply light pressure proximal to the IV site. B. Assess the radial pulse distal to the IV site. C. Assist the client to straighten the right arm. D. Elevate the client's right arm on one pillow.

Correct Answer is C

Explanation

A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.
B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.
C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.
D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client has an IV solution infusing through a catheter inserted in the right antecubital area. The infusion pump is alarming and indicates an occlusion. Which action should the nurse take?

Correct Answer is C

Explanation

Which client is at greatest risk for aspiration?

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A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

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To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?