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 C
Explanation
Rationale:
A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.
B. A recent colonoscopy is not relevant to the client's current symptoms.
C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.
D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.
Correct Answer is B
Explanation
Rationale:
A. Rubber-soled slippers do not provide adequate support or stability for a client with weakness.
B. Tennis shoes with velcro offer good support, stability, and ease of use, which is important for clients with weakness or impaired mobility.
C. Leather-soled loafers may be slippery and do not provide as much support or stability.
D. Slip-on rubber shower shoes lack adequate support and can be unsafe for ambulation.