A nurse is caring for a client.

Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1500:

Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.

1730:

Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.

Vital Signs

1730:

• Temperature 37.2° C (98.9° F)
• Blood pressure 168/84 mm Hg
• Heart rate 116/min
• Respiratory rate 24/min
• Oxygen saturation 93% on room air

Choice A reason:
Obtaining printed information about insulin self-administration is a first recommendation as it can be done after ensuring the client's ability to afford the supplies.
Choice B reason:
Making a copy of the medication reconciliation form for the client is not a first recommendation as it can be done after ensuring the client's access to supplies.
Choice C reason:
Determining whether the client can afford the insulin administration supplies is the first action to be taken. The first step should be to ensure that the client can afford the insulin administration supplies. Proper management of diabetes requires having access to the necessary equipment, including insulin, syringes, pens, or other devices. If the client cannot afford these supplies, alternative options or assistance programs may need to be explored to ensure the client's safety and well-being.
Choice D reason:
Providing the client with the contact number for a diabetes education specialist is important for long-term management, but addressing the affordability of supplies should take precedence initially.

Choice A reason:
Increased night-time sleeping is the appropriate finding. As individuals age, it is common for their sleep patterns to change. Older adults often experience changes in their sleep duration, including increased night-time sleeping and daytime napping. This can be attributed to changes in circadian rhythm and other factors.
Choice B reason:
A heightened sense of pain is incorrect. Older adults may experience a decreased sensitivity to pain, known as hypoalgesia, due to changes in the nervous system.
Choice C reason:
Decreased sense of balance is incorrect. While changes in balance can occur with aging, they are not universal. Many older adults maintain good balance through exercise and other strategies.
Choice D reason:
Night-time urinary incontinence is incorrect. While some older adults may experience night-time urinary incontinence, it is not a universally expected finding and can be influenced by various factors, including overall health and lifestyle.