A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

Exhibits

Which of the following are the most appropriate interventions for this client? Select all that apply.

Choice A rationale

Demonstrating the self-injection technique is a practical way for the nurse to evaluate the adolescent's ability to perform the procedure correctly. This hands-on approach allows the nurse to observe technique accuracy and provide corrective feedback if needed. It also helps build the adolescent’s confidence in self-administering insulin, which is crucial for managing type 1 diabetes mellitus independently. Furthermore, demonstrating skills to peers can reinforce learning as it involves active engagement and peer teaching, which have been shown to enhance knowledge retention and skill proficiency.

Choice B rationale

Asking the adolescent to describe his level of comfort with injecting himself provides subjective feedback rather than an objective measure of his ability to perform the procedure correctly. Comfort level does not necessarily correlate with competency in technique. However, assessing comfort can be part of a comprehensive evaluation but should not be the sole method. Comfort levels might influence adherence to the injection regimen, but they do not directly indicate whether the injection is being done correctly.

Choice C rationale

Reviewing glycosylated hemoglobin (HbA1c) levels can provide information about long-term blood glucose control but does not directly evaluate the adolescent's insulin injection technique. HbA1c reflects average blood glucose levels over the past 2-3 months and is influenced by multiple factors, including diet, physical activity, and overall diabetes management. While important for monitoring diabetes control, it is not a specific measure of the effectiveness of teaching self-injection techniques.

Choice D rationale

Having the adolescent list the procedural steps for safe insulin administration tests his recall of the steps but does not ensure that he can perform the injection correctly. Verbalizing steps is important for cognitive understanding but does not equate to the physical ability to execute the procedure. This approach may reveal gaps in knowledge but does not provide a comprehensive assessment of the actual injection technique.

Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.

Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.

Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.

Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.