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. Begin with queries that are less sensitive in nature. B. Ask queries in a vague, non-specific format. C. Get the most difficult queries over with first. D. Share personal values to put the client at ease.

Correct Answer is A

Explanation

Choice A rationale

Beginning with queries that are less sensitive in nature can help establish rapport and trust with the client. This approach makes the client more comfortable and willing to disclose personal information, including details about sexual activity.

Choice B rationale

Asking queries in a vague, non-specific format may lead to confusion and incomplete information. It is important to ask clear and direct questions to obtain accurate information.

Choice C rationale

Getting the most difficult queries over with first may cause the client to feel uncomfortable and defensive, making it harder to obtain accurate information.

Choice D rationale

Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse should maintain a neutral and non-judgmental approach to encourage open communication.

A. Request removal initiated by the Health Information Manager. B. Make an electronic addendum following the 1400 documentation. C. Create an electronic correction after 1400 notes are officially unlocked. D. Enter the occurrence after the 1400 notes and identify as “late entry.”.

Correct Answer is D

Explanation

Choice A rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an acceptable practice but may not provide sufficient clarity regarding the timing of the documentation.

Choice B rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation.

Choice C rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice D rationale

Making an electronic addendum following the 1400 documentation allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact.

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is D

Explanation

Quick Links

Resources

Free Nursing Test Bank

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?

Correct Answer is A

Explanation

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

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.

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?

The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

A client voided clear, yellow urine.

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?

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?

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

Quick Links

Resources