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 C
Explanation
Choice A rationale
Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.
Choice B rationale
Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.
Choice C rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.
Choice D rationale
Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading.
Correct Answer is B
Explanation
Choice A rationale
Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.
Choice B rationale
2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.
Choice C rationale
Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.
Choice D rationale
Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.