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.
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.
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View Related questions
Correct Answer is D
Explanation
Choice A rationale
Placing the client on contact precautions is not necessary for a blood glucose result of 104 mg/dL. Contact precautions are used to prevent the spread of infectious agents, not for managing blood glucose levels.
Choice B rationale
Starting a high-fiber diet is not indicated for a blood glucose result within the normal range. While a high-fiber diet can help manage blood glucose levels, it is not necessary for a result of 104 mg/dL56.
Choice C rationale
Administering an oral steroid is not appropriate for managing a blood glucose result of 104 mg/dL. Steroids can actually increase blood glucose levels and are not used for this purpose.
Choice D rationale
Making the client NPO (nothing by mouth) is not necessary for a blood glucose result of 104 mg/dL. This result is within the normal range, and no immediate dietary restrictions are required.
Correct Answer is C
Explanation
Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The priority is to address the client’s comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position may help with breathing but does not directly address the issue of dry mucous membranes.
Choice C rationale
Keeping mucous membranes moist is crucial for the comfort of a terminally ill client who is mouth breathing and refusing anything to eat or drink. This intervention helps prevent dryness and discomfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client in this condition. The priority is to address the client’s comfort and hydration.