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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. After each instruction, ask if the client understands:

While checking for understanding after each instruction is important, it may not accurately assess the client's ability to perform wound care independently. Verbal confirmation does not ensure competency in wound care techniques.

B. Have an interpreter repeat the wound care instructions:

Having an interpreter repeat the wound care instructions may help ensure accurate communication, but it does not assess the client's ability to perform the wound care independently.

C. Provide written instructions in the client's native language:

Providing written instructions in the client's native language can be helpful for reference, but it may not effectively assess the client's understanding or ability to perform the wound care.

D. Have the client demonstrate prescribed wound care:

This is the most appropriate method for evaluating the client's understanding of self-care at home. Having the client demonstrate wound care techniques allows the nurse to directly observe the client's competency in performing the necessary tasks. It provides a practical assessment of the client's ability to independently manage wound care post-discharge. If the client is unable to demonstrate the procedure correctly, the nurse can provide additional education and support as needed.

A. "This unit has a policy against staff harassment." B. "It is important to dress the right arm first." C. "Dressing must be a frustrating experience for you." D. "We will give you a class on dressing tomorrow." E. Monitor the client's white blood cell count.

Correct Answer is C

Explanation

A. "This unit has a policy against staff harassment."

This response addresses the client's cursing behavior directly and attempts to establish boundaries by referring to the unit's policy. However, it may come across as confrontational and could potentially escalate the situation further. While it's important to address inappropriate behavior, in this case, responding with empathy and understanding might be more effective in de-escalating the situation and building rapport.

B. "It is important to dress the right arm first."

This response focuses on the physical aspect of dressing and does not acknowledge the client's frustration or emotional state. While it provides guidance on dressing technique, it does not address the underlying issue of the client's struggle or emotional distress. In this situation, addressing the client's emotional needs and frustrations may be more beneficial.

C. "Dressing must be a frustrating experience for you."

This response demonstrates empathy and understanding towards the client's frustration. It acknowledges the client's emotional state and validates their feelings, which can help build rapport and trust. By expressing empathy, the nurse can create a supportive environment and open the door for effective communication with the client.

D. "We will give you a class on dressing tomorrow."

This response offers a solution for the future but does not address the client's immediate frustration or emotional distress. While education on dressing techniques may be helpful in the long run, it does not address the client's current struggle or provide support in the moment. In this situation, addressing the client's emotional needs and frustrations should take priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

Correct Answer is D

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?