Today’s NCLEX-RN® question of the day focuses on a nurse who is caring of a post-appendectomy patient. What is the most suitable outcome statement to address and improve the patient’s ability to engage in activities without experiencing undue shortness of breath and the need for frequent breaks? Can you figure it out?
The nurse is caring for a patient who underwent a complicated appendectomy and is set to be discharged in a few days. The nurse notes the patient is short of breath with ambulation and requires frequent breaks during activity. Based on these findings, the nurse chooses a priority hypothesis of impaired activity tolerance. Which is the most appropriate outcome statement to address this hypothesis?
A. The patient will be logrolled by nursing staff every 2 hours
B. The patient will participate in cough and deep breathing exercises twice per day
C. The patient will utilize a wheelchair for transportation
D. The patient will tolerate ambulating 25 feet in the hall without reports of fatigue or shortness of breathScroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
D. The patient will tolerate ambulating 25 feet in the hall without reports of fatigue or shortness of breath
Rationale: An appropriate outcome for this patient is to tolerate ambulating 25 feet in the hall without reports of fatigue or shortness of breath. This outcome is specific to the priority hypothesis, measurable, achievable, realistic, and time specific.
Major Takeaway
The nurse should use clinical judgment to generate solutions related to mobility alterations, which involves identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes. For patients with a priority hypothesis of impaired activity tolerance, it is crucial for the nurse to encourage the patient to ambulate as early as possible. This prevents muscle atrophy, as well as reduces the risk of wounds, falls, deep vein thrombosis, and further respiratory complications. Outcomes should be patient centered, specific, measurable, achievable, realistic, and time specific.
Incorrect answer explanations
A. The patient will be logrolled by nursing staff every 2 hours
Rationale: This scenario does not indicate that this patient needs to be logrolled, which is common for patients with spinal cord injuries.
B. The patient will participate in cough and deep breathing exercises twice per day
Rationale: While coughing and deep breathing exercises are important to eliminate excess mucus from pneumonia, they do not address the priority hypothesis.
C. The patient will utilize a wheelchair for transportation
Rationale: There is no assessment information that indicates the patient requires a wheelchair.
________________________
Want more NCLEX®-style practice questions? Try Osmosis by Elsevier today! Access your free trial and find out why millions of current and future clinicians and caregivers love learning with us.
Leave a Reply