Nokea
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?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
You may also like to solve these questions
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?
- 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.'
Correct Answer: B
Rationale: Empathy encourages communication.
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?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.
A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
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. Have the client demonstrate prescribed wound care.
- B. After each instruction, ask if the client understands.
- C. Have an interpreter repeat the wound care instructions.
- D. Provide written instructions in the client’s native language.
Correct Answer: A
Rationale: Demonstration confirms skill.