Take full exam for free

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 demonstrate the ability to change the ostomy bag in two days.

The client attempts to self-administer insulin but is unable to perform the injection.

The client’s breath sounds will be auscultated by the nurse every 4 hours.

The client will adhere to the medication regimen after discharge.

Answer and Explanation

The Correct Answer is D

Choice A rationale

This outcome statement focuses on the client’s ability to perform a specific task related to ostomy care. While it’s important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

Choice B rationale

This outcome statement indicates the client’s attempt to self-administer insulin but inability to perform the injection. While it’s important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

Choice C rationale

This outcome statement focuses on monitoring the client’s respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client’s primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

Choice D rationale

This outcome statement directly addresses the client’s need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client’s health needs and goals following the surgical procedure and the development of hyperglycemia.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Offering therapeutic support and comfort to a grieving family. B. Obtaining clarification from a client’s healthcare power-of-attorney. C. Reporting a change in a client’s condition to the healthcare provider. D. Completing discharge teaching to a client and family members.

Correct Answer is C

Explanation

Choice A rationale

Offering therapeutic support and comfort to a grieving family does not typically require the structured communication format of SBAR. This interaction is more about providing emotional support and empathy rather than conveying specific clinical information.

Choice B rationale

Obtaining clarification from a client’s healthcare power-of-attorney may involve detailed discussions, but it is not the primary context for SBAR. SBAR is designed for concise, structured communication about clinical situations.

Choice C rationale

Reporting a change in a client’s condition to the healthcare provider is the ideal scenario for using SBAR. This format ensures that critical information is communicated clearly and efficiently, which is essential for patient safety and effective clinical decision-making.

Choice D rationale

Completing discharge teaching to a client and family members involves providing comprehensive education and instructions, which is not the primary purpose of SBAR. SBAR is more suited for brief, focused communication about specific clinical issues.

A. Gives the client a hug and says, “It’s okay to cry when you are sad.”. B. While touching the client’s forearm, asks, “Would you like to talk about it?” C. “I’m sorry to disturb you at a difficult time.This can wait until later.”. D. “This is a bad time.I can see you are upset. I can come back later.”.v

Correct Answer is B

Explanation

Choice A rationale

Giving the client a hug may not be appropriate in a professional setting and could be perceived as crossing personal boundaries.

Choice B rationale

While touching the client’s forearm, asking “Would you like to talk about it?” is a compassionate and supportive response. It shows empathy and provides the client with an opportunity to express their feelings.

Choice C rationale

Apologizing for disturbing the client and offering to wait until later may not address the client’s immediate emotional needs.

Choice D rationale

Stating that it is a bad time and offering to come back later may not provide the client with the support they need in the moment.

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is B

Explanation

Quick Links

Resources

Free Nursing Test Bank

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Correct Answer is C

Explanation

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to the client about sexual activity. Which approach is best for the nurse to use?

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer.The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

What times should the nurse measure vital signs? Select all that apply.

Which assessment should the nurse document when charting by exception?

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

To assess the quality of the client’s abdominal pain, which approach should the nurse use?

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?

Quick Links

Resources