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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Keeping a pair of gloves in a uniform pocket:
While it may be convenient to carry gloves, this action alone does not necessarily indicate an understanding of appropriate gloving procedures. Simply having gloves readily available does not ensure that they are used correctly or in accordance with infection control protocols.
B. Using sterile gloves when handling body fluids:
This action indicates an understanding of the need for sterile gloves when handling potentially infectious body fluids. However, it's important to note that not all situations require sterile gloves, and the use of sterile gloves should be based on the specific clinical context and infection control guidelines.
C. Donning sterile gloves when caring for clients with HIV:
While wearing gloves when caring for clients with HIV is important for infection control, not all situations require sterile gloves. The use of sterile gloves should be based on the specific clinical context and infection control guidelines.
D. Putting on new gloves when entering a client's room:
This action demonstrates an understanding of the importance of donning clean gloves when entering a client's room to prevent the spread of infection. It indicates adherence to standard precautions and proper infection control practices, making it the most appropriate choice.
Correct Answer is B
Explanation
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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