A nurse is caring for a client who has type 2 diabetes mellitus. Which of the following findings should the nurse identify as manifestations of hypoglycemia?

Rationale

A. Instruct the client to use the incentive spirometer five times per hour: Frequent use of the incentive spirometer promotes lung expansion, prevents atelectasis, and improves oxygenation postoperatively, especially when lung sounds are diminished.

B. Administer ondansetron: Ondansetron addresses nausea but does not directly improve respiratory status. While important for comfort, it is not a primary intervention for pulmonary function.

C. Encourage the client to splint the abdomen: Splinting the incision during coughing or deep breathing reduces pain, allowing the client to perform respiratory exercises effectively and decrease the risk of atelectasis or hypoventilation.

D. Encourage the client to cough and breathe deeply: Deep breathing and coughing mobilize secretions, enhance alveolar ventilation, and prevent postoperative pulmonary complications, which is critical given the client’s diminished lung sounds and shallow respirations.

E. Administer supplemental oxygen: Supplemental oxygen can help improve oxygen saturation in clients with hypoxemia, as indicated by the drop to 92% on room air.

F. Ambulate the client 30 min after administering analgesia: Early ambulation enhances lung expansion, promotes circulation, and helps prevent pulmonary complications. Providing analgesia beforehand minimizes pain and encourages participation.

G. Administer acetaminophen: Acetaminophen may reduce fever and mild pain but does not directly improve respiratory status or lung expansion, so it is not a primary intervention in this scenario.

Rationale:

A. Hypertrophic Scar: This image shows an abnormal, raised scar that is wider and more prominent than a normal healing scar, likely a hypertrophic scar which results from excessive collagen deposition during the healing process.

B. Dermatographia: This image displays urticarial (hive-like) lesions that appear as linear welts or swelling (wheals) on the skin of an arm. This is a common form of physical urticaria (hives). It is an exaggerated local skin response where light pressure, friction, or scratching results in localized vasodilation (redness) and edema (swelling/wheals) along the line of contact.

C. Psoriatic Plaque: This image displays a classic plaque-like lesion characteristic of Psoriasis. The characteristic features, a sharply demarcated, thickened (plaque), silvery-white scale covering a bright red, erythematous base. These plaques are often found symmetrically on the elbows, knees, scalp, and lower back.

D. Folliculitis: The lesions typically present as small, red bumps or pimples that may have a white or yellow center (a pustule) and usually center around a hair. The lesions in the image are discrete, erythematous (reddened), and scattered.