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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?

A.

Avoid pain-causing activity.

B.

Ambulate without discomfort.

C.

Show evidence of incision healing.

D.

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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Correct Answer is B

Explanation

Rationale:

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B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.

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Correct Answer is B

Explanation

Rationale:

A. Assessing the impact of hearing loss on daily activities is important but not the immediate follow-up question to understand the nature of the hearing loss.

B. Asking about balance issues is essential because it could indicate an inner ear problem, which often affects both hearing and balance.

C. A history of ear infections could be relevant but is not as immediately necessary for determining the cause of the current symptoms.

D. Considering a hearing aid is a step for management, but determining the nature and cause of the hearing loss is the priority.

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