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 B
Explanation
A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratory function, these parameters are not the most direct indicators of fluid volume status.
Correct Answer is B
Explanation
A. Rinsing the mouth with mouthwash is not sufficient for managing oral lesions, and some mouthwashes may contain alcohol that can further irritate the lesions; therefore, this intervention is inadequate.
B. Performing mouth care before and after every meal can help minimize discomfort, remove debris, and maintain oral hygiene, which is crucial for someone with painful oral lesions to encourage better nutritional intake.
C. Offering three meals with a bedtime snack may not be effective if the client is unable to eat comfortably; focusing on smaller, more frequent meals or nutrient-dense options may be more beneficial.
D. While assessing oral pain is important, it should occur more frequently than once per shift to ensure ongoing management and adjustment of care based on the client’s comfort and needs.