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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

Rationale:

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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A. Prepare to administer a glucose, then insulin, then potassium infusion. B. Instruct the client to increase daily intake of potassium rich foods. C. Inform the healthcare provider of the need for potassium replacement. D. Change the plan of care to include hourly urinary output measurements. E. Change the plan of care to include hourly urinary output measurements.

Correct Answer is C

Explanation

Rationale:

A. The combination of glucose and insulin is used to shift potassium into cells, which would lower serum potassium levels further; this is not appropriate for treating hypokalemia.

B. Increasing dietary intake of potassium is important but not sufficient to correct a serum potassium level as low as 2.5 mEq/L, which requires more immediate intervention.

C. A potassium level of 2.5 mEq/L is critically low and can lead to life-threatening cardiac arrhythmias. The healthcare provider should be informed immediately to initiate potassium replacement therapy, likely via intravenous infusion.

D. Hourly urinary output measurements may be useful but are not the immediate priority in treating severe hypokalemia.

A. Place the vial with the remainder of the medication into a locked drawer. B. Ask another nurse to witness the medication being discarded. C. Withdraw the medication into a syringe and label it with the client's name. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is B

Explanation

Rationale:

A. Storing the remainder of the medication in a locked drawer is not appropriate for controlled substances that are not fully administered.

B. Lorazepam is a controlled substance, and any unused portion must be disposed of according to hospital policy, typically by discarding it with a witness. The presence of another nurse to witness the discarding process ensures proper documentation and compliance with legal regulations.

C. Withdrawing the medication into a syringe and labeling it is unsafe as it may lead to medication errors or misuse.

D. Simply throwing the vial into the trash, even with another nurse present, does not comply with the proper disposal procedure for controlled substances.

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is C

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

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In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

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