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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. Provide client with dietary teaching regarding a cardiac diet. B. Obtain client's vital signs every 4 hours when awake. C. Obtain a blood pressure reading before client gets out of bed. D. Measure and record the client's urinary output every day.

Correct Answer is C

Explanation

Rationale:

A. Dietary teaching is important for long-term health but does not address the immediate issue of dizziness upon standing.

B. Monitoring vital signs every 4 hours is important, but obtaining blood pressure before standing is crucial to prevent falls and manage orthostatic hypotension.

C. Measuring blood pressure before the client stands helps identify orthostatic hypotension, which could be causing weakness and dizziness.

D. Measuring urinary output is relevant but not immediately pertinent to the client's dizziness and weakness on standing.

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Correct Answer is C

Explanation

Correct Answer is C

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

Correct Answer is C

Explanation

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