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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. Administer albuterol via nebulizer. B. Listen to the lungs fields. C. Measure urine output. D. Review serum potassium.

Correct Answer is B

Explanation

Rationale:

A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.

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.

C. Measuring urine output is important but secondary to assessing respiratory status.

D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.

A. Advise the client to see his healthcare provider for immediate evaluation. B. Encourage the client to keep checking the mole with a magnifying mirror. C. Ask the client if he often spends time outside in the sun without a shirt. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

Rationale:

A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.

B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.

C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.

D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

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