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.
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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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.
Correct Answer is D
Explanation
Rationale:
A. Renal creatinine clearance is important in assessing kidney function but is not directly related to divalproex sodium therapy.
B. While CBC monitoring is essential, especially for detecting thrombocytopenia, liver function tests are more critical in this context.
C. A chemistry panel is valuable but does not specifically monitor for the primary risks associated with divalproex sodium.
D. Divalproex sodium (valproate) can cause hepatotoxicity, so monitoring liver function tests (LFTs) is crucial. Regular LFTs help detect early signs of liver damage, which can be a serious adverse effect of this medication.