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. Insulin requirements generally increase as pregnancy progresses due to the growing placenta and hormones that cause insulin resistance, not fluctuate significantly.
B. Insulin requirements typically begin to increase around 18 weeks of gestation and continue to rise until approximately 36 weeks due to increased insulin resistance caused by placental hormones.
C. While insulin needs do increase, they do not typically double or quadruple during the second trimester. The increase is more gradual.
D. Insulin requirements increase during pregnancy and may decrease after delivery as the placenta is no longer present, removing the source of insulin resistance.
Correct Answer is C
Explanation
Rationale:
A. A white blood cell count of 8,000/mm³ is within the normal range and does not indicate a need for dosage adjustment.
B. Inelastic skin turgor may indicate dehydration or aging but does not directly affect drug dosage.
C. Elevated serum creatinine levels indicate impaired renal function, which necessitates a reduced dosage of medications excreted through the kidneys, such as ticarcillin disodium.
D. Thin, fragile veins are a concern for intravenous access but do not affect the medication dosage.