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 A
Explanation
Choice A rationale
The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.
Choice B rationale
Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.
Choice C rationale
Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.
Choice D rationale
Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.
Choice B rationale
Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.
Choice C rationale
Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.
Choice E rationale
Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.