The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
The client will demonstrate ability to change the ostomy bag in two days.
The client will adhere to the medication regimen after discharge.
The client's breath sounds will be auscultated by the nurse every 4 hours.
The client attempts to self administer Insulin but is unable to perform injection.
The Correct Answer is B
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtaining clarification from a client's healthcare power-of-attorney:
While clear communication is important in this scenario, SBAR may not be necessary as the nurse is seeking information rather than providing a detailed report or recommendation.
B. Completing discharge teaching to a client and family members:
SBAR may not be the most suitable format for discharge teaching, as it is primarily used for communication between healthcare providers regarding a patient's condition and care plan. Discharge teaching typically involves providing comprehensive instructions and information in a manner tailored to the needs of the client and family members.
C. Reporting a change in a client's condition to the healthcare provider:
This is the most appropriate scenario for using the SBAR format. When communicating a change in a client's condition to the healthcare provider, the SBAR framework allows the nurse to provide a concise summary of the situation, relevant background information, assessment findings, and recommendations for further action.
D. Offering therapeutic support and comfort to a grieving family:
SBAR communication is not suitable for offering therapeutic support and comfort to a grieving family. This interaction requires empathy, active listening, and emotional support rather than a structured communication format like SBAR.
Correct Answer is A
Explanation
A. Provide a back rub at bedtime:
This intervention addresses the client's immediate need for comfort and relaxation without resorting to restrictive measures or medications.
B. Leave the door to the client's room open slightly:
Leaving the door open may not prevent wandering and could potentially lead to safety issues.
C. Apply wrist restraints to prevent wandering:
Restraints should only be used as a last resort and when all other interventions have failed. They pose risks to the client's physical and psychological well-being and should be avoided whenever possible.
D. Administer a PRN sedative prescription:
Sedatives should be used judiciously and only after other non-pharmacological interventions have been attempted. Sedating the client may increase the risk of falls or injury and should not be the first-line intervention for managing sleep disturbances or wandering behavior.
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