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 B
Explanation
Choice A rationale
Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.
Choice B rationale
Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.
Choice C rationale
Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.
Choice D rationale
Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.
Correct Answer is B
Explanation
Choice A rationale
Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.
Choice B rationale
Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.
Choice C rationale
Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.
Choice D rationale
Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.