Activity InTolerance Q1: A postoperative client will be getting out of bed and walking to the chair for the first time since surgery. Which intervention by the nurse is best? A. Pre-medicate the client for pain prior to the activity. (Correct) B. Take the client’s vital signs prior to beginning the activity. C. Call the provider and request a physical therapy consultation. D. Encourage the client to do as much as possible him- or herself. Rationale: Pain often limits a client’s activity and/or willingness to participate in activity. Pre-medicating the client beforehand will allow the client to be active while remaining as comfortable as possible. Baseline vital signs might be an important assessment, but is not as important as providing pain control. There is no indication for the client to require physical therapy. Simply encouraging the client will not help if the client’s pain level prevents participation. DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Implementation MSC: Physiological Integrity: Pharmacological and Parenteral Therapies
Q2: A nurse is ambulating a client in the hallway. The client begins to act confused and seems weaker than earlier. Which action by the nurse takes priority? A. Stop ambulating the client and have someone bring a wheelchair. (Correct) B. Return the client to bed immediately, ambulating slowly. C. Have the client rest, then resume ambulating at a slower pace. D. Encourage the client to take slow deep breaths while returning to bed. Rationale: This patient may be experiencing cardiac decompensation and should stop all activity immediately to reduce the risk of a fall. The nurse should remain with the client and have someone else bring a wheelchair so the client can be returned to bed. The other activities are not appropriate as they will place more stress on the client’s heart. DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Implementation MSC: Physiological Integrity: Physiological Adaptation
Q3: A client has been on bed rest for several weeks and now has orders to begin increasing activity as tolerated. The client is concerned about tolerating more activity. Which action by the nurse is best? A. Teach the client about the benefits of increased activity. B. Assist the client in setting realistic short-term activity goals. (Correct) C. Discuss all the potential complications of remaining bedfast. D. Call the provider and request a physical therapy consultation. Rationale: Clients who have helped set goals are more likely to participate in activities that help reach that goal. For a client who is apprehensive about increasing activity, mutually agreeing on short-term goals could help encourage the client to try the activities. Teaching the client about the benefits of activity and about the complications of immobility are certainly important, but may not convince a client to participate. A physical therapy consultation is not indicated in this situation. DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Planning MSC: Physiological
Ackley & Ladwig's Nursing Problems & Care Planning Handbook An Evidence: Based Approach 14e Makic Test Bank