The client attempts to self-administer insulin but is unable to perform the injection. 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 requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
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 will demonstrate the ability to change the ostomy bag in two days.
The client will be able to self-administer insulin injections before discharge.
The Correct Answer is D
Choice A rationale
Adhering to the medication regimen is important, but it does not specifically address the client’s ability to self-administer insulin, which is crucial for managing hyperglycemia post- discharge.
Choice B rationale
Auscultating breath sounds every 4 hours is important for monitoring respiratory status but does not address the client’s need to manage their diabetes through self-injection of insulin.
Choice C rationale
Demonstrating the ability to change the ostomy bag is important for postoperative care but does not address the specific need for managing hyperglycemia through insulin self- administration.
Choice D rationale
Ensuring the client can self-administer insulin injections before discharge is crucial for managing their hyperglycemia and maintaining their health post-discharge.
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Correct Answer is D
Explanation
Choice A rationale
Risk for infection is a concern for clients with neuropathy, as they may have reduced sensation and be unaware of injuries that can become infected. However, the primary concern in promoting foot care is preventing the occurrence of wounds or skin breakdown in the first place.
Choice B rationale
Self-care deficit is relevant for clients with neuropathy who may have difficulty performing foot care independently. However, the priority is to prevent skin breakdown and wounds, which can lead to more severe complications.
Choice C rationale
Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and ensuring proper foot care to avoid complications.
Choice D rationale
Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and maintaining skin integrity is crucial in this scenario.
Correct Answer is ["B","E"]
Explanation
Choice A rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.
Choice B rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.
Choice C rationale
Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep
.
Choice D rationale
Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.
Choice E rationale
Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.