The nurse is performing discharge planning for a client newly diagnosed with type 1 diabetes mellitus. It would be most important for the plan to include:
using a 23 gauge 1/2 inch needle for subcutaneous insulin.
monitoring the skin for dryness at injection site.
reporting multiple consecutive blood glucose levels over 200 mg/dL.
emphasizing the need to get eyes checked every 3 months.
The Correct Answer is C
A. While using the correct needle size is important for insulin administration, it is not the most critical aspect of discharge planning. The focus should be on managing blood glucose levels and recognizing when medical intervention is needed.
B. Monitoring the skin for dryness at the injection site is a good practice, but it is not the most urgent issue to address in discharge planning for a newly diagnosed diabetic client.
C. Consistently elevated blood glucose levels above 200 mg/dL may indicate poor control of diabetes and require prompt adjustments in treatment. Teaching the client to recognize and report hyperglycemia is essential to prevent complications such as diabetic ketoacidosis (DKA).
D. Eye exams are important for long-term diabetes management to monitor for diabetic retinopathy, but every 3 months is excessive. Annual eye exams are typically sufficient unless otherwise indicated by the healthcare provider.
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Correct Answer is C
Explanation
A. Reading glasses do not offer sufficient protection against the light sensitivity that results from photodynamic therapy. Special protective eyewear is needed to protect the eyes from exposure to bright light during recovery.
B. Clients are usually instructed to fast before treatments that involve anesthesia or sedation, such as photodynamic therapy. Eating a full breakfast is not typically recommended before this type of treatment.
C. After photodynamic therapy, clients become extremely sensitive to light, including sunlight. Exposure to sunlight or strong indoor lights can cause skin damage, so clients are advised to avoid sun exposure for at least 6 weeks.
D. Skin markings made for treatment guidance should be preserved between treatments, but this is less critical in photodynamic therapy compared to radiation therapy, where precise location is essential for targeting tumors.
Correct Answer is C
Explanation
A. While no episodes of diarrhea may be beneficial, it is not a direct indicator of the effectiveness of ondansetron, which is used primarily to prevent nausea and vomiting.
B. Maintaining a normal hemoglobin level is not an expected outcome related to ondansetron, as it does not influence blood counts.
C. The ability to tolerate oral fluid intake indicates that the client is managing nausea effectively, demonstrating that ondansetron is working as intended.
D. Hair loss is a common side effect of many chemotherapeutic agents, and ondansetron does not affect this outcome. Therefore, it is not an appropriate indicator of the medication's effectiveness.