The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)

A. Plan meals with low fiber: After bariatric surgery, the digestive system can be more sensitive, and high-fiber foods may cause discomfort. Planning low-fiber meals helps reduce irritation and minimize symptoms like diarrhea and cramping.

B. Separate fluids from meals: This is an important intervention because drinking fluids during meals can increase the risk of dumping syndrome, leading to nausea, vomiting, and diarrhea. Fluids should be consumed between meals to help avoid these symptoms.

C. Eliminate acidic food choices: Acidic foods (like citrus, tomatoes, some sauces) can irritate the sensitive gastric pouch and small intestine after bariatric surgery, potentially exacerbating symptoms of nausea, abdominal cramps, and discomfort.

D. Offer comfort foods: Comfort foods are not appropriate for this client, as they may be high in fat, sugar, or calories, which could exacerbate symptoms after bariatric surgery. Instead, nutritious and easily digestible foods should be offered.

E. Provide small, frequent meals: Offering small, frequent meals helps reduce the strain on the digestive system, making it easier for the client to tolerate food. Large meals can cause discomfort and increase the risk of complications such as dumping syndrome.

Rationale for Correct Choices:

• Nephrotic Syndrome: The child’s symptoms, including edema, fatigue, increased weight despite decreased appetite, and proteinuria, point towards nephrotic syndrome. This condition involves the loss of protein (mainly albumin) in the urine, leading to edema. The laboratory result of 2+ protein in the urine and low albumin level of 2.8 g/dL are consistent with nephrotic syndrome.
• Provide a low-salt diet: A low-salt diet is a key intervention in nephrotic syndrome to help manage fluid retention and edema. Sodium causes water retention, which worsens edema, and limiting salt intake can help reduce swelling and manage the symptoms effectively.
• Administer albumin: Administering albumin is important in nephrotic syndrome because it helps replenish the albumin levels in the blood. Restoring the albumin levels can help reduce edema by improving osmotic pressure and preventing fluid from accumulating in the tissues.
• Daily weight: Daily weight monitoring is essential to assess for changes in fluid retention. In nephrotic syndrome, fluid retention can fluctuate, and regular monitoring helps assess the effectiveness of the treatment plan and helps guide further interventions.
• Abdominal girth: Monitoring abdominal girth is necessary to track the extent of fluid accumulation in the abdomen. Abdominal edema is common in nephrotic syndrome, and significant increases in girth could indicate worsening fluid retention.

Rationale for Incorrect Choices:

• Type 1 diabetes: This presents with increased thirst, frequent urination, and weight loss due to elevated blood glucose levels. However, this child is experiencing weight gain despite decreased appetite and has symptoms of edema, which are not typical of diabetes.
• Wilms' tumor: Wilms' tumor presents with an abdominal mass, hematuria, or pain, which is not mentioned in this case. While renal issues could cause edema, the lab results of proteinuria and low albumin suggest nephrotic syndrome rather than a malignancy like Wilms' tumor.
• Hemolytic uremic syndrome: Hemolytic uremic syndrome is characterized by hemolytic anemia, thrombocytopenia, and acute kidney injury. The child does not show signs of anemia, low platelets, or kidney failure (such as elevated creatinine), which are key features of HUS.

• Place the child on strict bed rest While it’s important to monitor the child closely, strict bed rest could lead to muscle weakness and decreased mobility. The focus should be on managing edema and ensuring proper fluid balance, not restricting movement.
• Prepare the child for emergency surgery: Emergency surgery is not indicated for nephrotic syndrome, which is a non-surgical condition that can be managed with medications (like albumin) and lifestyle adjustments (such as a low-salt diet).
• Prepare an insulin drip: An insulin drip would be appropriate for managing hyperglycemia, typically seen in diabetic emergencies. However, this child does not show any signs of diabetes or hyperglycemia. The focus is on managing nephrotic syndrome.

• Lymph node size: Lymph node size is monitored in cases of infection or malignancy. In nephrotic syndrome, the primary concern is fluid retention and protein loss, not lymph node enlargement.
• Bladder volume: Bladder volume monitoring is typically relevant in cases of urinary retention or other urinary tract disorders. This child’s primary concern is proteinuria and edema, which are linked to kidney function and fluid balance, rather than bladder volume.
• Ketones: Monitoring ketones is generally relevant in cases of uncontrolled diabetes or prolonged fasting. However, this child is not presenting with symptoms of hyperglycemia or ketosis. Nephrotic syndrome does not typically involve ketones.