Patient Data

Exhibits

Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies.

What times should the nurse measure vital signs? Select all that apply.

Choice A rationale
Having the client demonstrate prescribed wound care is the most effective method to evaluate the client’s understanding of self-care at home. This approach allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide immediate feedback and clarification as needed. Demonstration ensures that the client can correctly follow the wound care instructions, which is crucial for proper healing and preventing complications.
Choice B rationale
Asking the client if they understand after each instruction may not be effective, especially if the client is not comfortable expressing confusion or misunderstanding. This method relies on the client’s verbal confirmation, which may not accurately reflect their ability to perform the wound care tasks correctly.
Choice C rationale
Having an interpreter repeat the wound care instructions can help bridge the language barrier, but it does not allow for direct observation of the client’s ability to perform the necessary tasks. While the interpreter can ensure that the client understands the instructions, it does not provide the nurse with a way to assess the client’s practical skills.
Choice D rationale
Providing written instructions in the client’s native language can be helpful, but it does not allow the nurse to directly evaluate the client’s understanding and ability to perform the wound care tasks. Written instructions alone may not be sufficient for clients who have limited literacy or who may have difficulty following written directions.

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.