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.

None

Answer and Explanation

The Correct Answer is B

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Correct Answer is B

Explanation

A. Assess strength of deep tendon reflexes:

Hyperkalemia can affect neuromuscular function, leading to alterations in deep tendon reflexes. However, determining the apical pulse rate and rhythm is more crucial as hyperkalemia can cause cardiac dysrhythmias and cardiac arrest.

B. Determine apical pulse rate and rhythm:

This is the most important intervention because hyperkalemia can lead to life-threatening cardiac dysrhythmias, including ventricular tachycardia and ventricular fibrillation. Monitoring the apical pulse rate and rhythm allows the nurse to detect any abnormalities promptly.

C. Compare muscle strength bilaterally:

Hyperkalemia can cause muscle weakness or paralysis due to its effects on neuromuscular function. While assessing muscle strength is important, monitoring cardiac function takes precedence because of the potential for life-threatening dysrhythmias.

D. Observe color and amount of urine:

Hyperkalemia can affect renal function, leading to changes in urine output and composition. While monitoring urine output and characteristics is important for assessing renal function, it is not the most critical intervention when managing acute hyperkalemia and its potential cardiac effects.

A. Elevate the head of the bed to a 45 degree angle. B. Lift and lock the side rails in place. C. Apply the client's positive airway pressure device. D. Remove dentures or other oral appliance.

Correct Answer is C

Explanation

A. Elevate the head of the bed to a 45-degree angle:

Elevating the head of the bed can help improve airway patency and reduce the risk of airway obstruction in clients with OSA. While this intervention is important, applying the positive airway pressure device (CPAP or BiPAP) takes precedence due to its direct impact on maintaining airway patency and preventing respiratory compromise.

B. Lift and lock the side rails in place:

Ensuring the safety of the client by lifting and locking the side rails is important, but it does not directly address the client's OSA or the potential respiratory depression associated with opioid analgesic administration.

C. Apply the client's positive airway pressure device:

This is the most important intervention in this scenario. Clients with severe obstructive sleep apnea rely on positive airway pressure devices, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), to maintain airway patency and prevent episodes of apnea during sleep. Applying the device before leaving the client alone ensures continuous support for effective breathing.

D. Remove dentures or other oral appliance:

While removing dentures or other oral appliances may be necessary for client comfort and safety, it is not directly related to managing OSA or preventing respiratory compromise associated with opioid analgesic administration.

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Naxlex Comprehensive Predictor Exams

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

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?

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?