After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

A. The client will demonstrate ability to change the ostomy bag in two days.

This outcome statement focuses on the client's ability to perform a specific task related to ostomy care. While it's important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

B. The client will adhere to the medication regimen after discharge.

This outcome statement directly addresses the client's need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client's health needs and goals following the surgical procedure and the development of hyperglycemia.

C. The client's breath sounds will be auscultated by the nurse every 4 hours.

This outcome statement focuses on monitoring the client's respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client's primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

D. The client attempts to self-administer insulin but is unable to perform injection.

This outcome statement indicates the client's attempt to self-administer insulin but inability to perform the injection. While it's important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

A. Initiate the facility's restraint flow sheet:

- Initiating the facility's restraint flow sheet is an important step for documenting the use of restraints according to institutional policies and regulatory requirements. However, in this scenario where improper use of restraints has been observed, the immediate priority is to address the safety concern and prevent harm to the client.

B. Ensure that the restraints are not too tight:

- Ensuring that the restraints are not too tight is crucial for preventing harm to the client, such as compromised circulation or tissue damage. However, while important, this action is secondary to addressing the observed improper use of restraints, which poses an immediate safety risk to the client.

C. Demonstrate proper securing of the restraints:

Educating the UAP on how to correctly apply restraints is crucial. Incorrectly secured restraints can lead to complications such as injury, infection, or impaired circulation. The nurse should show the UAP how to secure the restraints to amovable part of the bed frame, not to the side rails. This ensures safety and prevents harm if the side rails are released.Proper restraint application helps maintain the client’s safety while minimizing risks.

D. Complete an adverse occurrence/incident report:

- Completing an adverse occurrence/incident report: Reporting incidents is necessary, but it can wait until after ensuring safe restraint application.