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 D

Explanation

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

A. "I'm sorry but your son's medical information is none of your business.". B. "The healthcare provider will share this information with you.". C. "I can only give medical information to your son because he is an adult.". D. "I will get these results back from the lab as soon as possible.".

Correct Answer is C

Explanation

The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.

Choice A is not the answer because it is rude and unprofessional.

Choice B is not the answer because it does not address the issue of privacy and confidentiality.

Choice D is not the answer because it does not address the issue of privacy and confidentiality.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is D

Explanation

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Correct Answer is C

Explanation

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

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Which response by the nurse is most therapeutic?

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