The client attempts to self-administer insulin but is unable to perform the injection.

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?

The client will adhere to the medication regimen after discharge.

The client’s breath sounds will be auscultated by the nurse every 4 hours.

The client will demonstrate the ability to change the ostomy bag in two days.

The client will be able to self-administer insulin injections before discharge.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Adhering to the medication regimen is important, but it does not specifically address the client’s ability to self-administer insulin, which is crucial for managing hyperglycemia post- discharge.

Choice B rationale

Auscultating breath sounds every 4 hours is important for monitoring respiratory status but does not address the client’s need to manage their diabetes through self-injection of insulin.

Choice C rationale

Demonstrating the ability to change the ostomy bag is important for postoperative care but does not address the specific need for managing hyperglycemia through insulin self- administration.

Choice D rationale

Ensuring the client can self-administer insulin injections before discharge is crucial for managing their hyperglycemia and maintaining their health post-discharge.

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Correct Answer is A

Explanation

Choice A rationale

When a child is on a clear liquid diet due to vomiting, it's essential to ensure that all consumed liquids are transparent and free from solid particles. Popsicles made from flavored gelatin are typically considered acceptable because they are clear and do not contain solid pieces. However, if the popsicles contain pulp or fruit, they would no longer be classified as clear liquids and could potentially irritate the stomach, leading to further vomiting. Therefore, the nurse should inquire whether the popsicles contain pulp or fruit to ensure they adhere to the clear liquid diet guidelines.

Choice B rationale

While the color and flavor of the gelatin may affect the child's acceptance of the popsicles, they do not impact whether the popsicles are considered clear liquids.

Choice C rationale

If the popsicles are completely frozen is not relevant to the dietary restrictions. The focus should be on the ingredients and their suitability for a clear liquid diet.

Choice D rationale

The number of popsicles available does not impact their suitability for the child’s diet. The nurse should focus on the content and appropriateness of the popsicles.

A. Positive external places. B. Tranquil sounds. C. Emotional reflection. D. Motivational phrases.

Correct Answer is A

Explanation

Choice A rationale

Positive external places are often used in guided imagery to help clients focus on pleasant and calming environments. This technique can help distract from pain and promote relaxation by engaging the mind in a soothing and peaceful visualization.

Choice B rationale

Tranquil sounds can also be beneficial in relaxation techniques, but they are not the primary focus in guided imagery for chronic pain. Guided imagery typically involves visualizing a serene place rather than focusing solely on sounds.

Choice C rationale

Emotional reflection may not be as effective in reducing chronic pain through guided imagery. This technique is more about visualizing positive and calming environments rather than reflecting on emotions.

Choice D rationale

Motivational phrases are useful in other therapeutic techniques but are not the primary focus in guided imagery for chronic pain. Guided imagery focuses more on visualizing serene and peaceful places.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is A

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client’s attention on which focus?

Correct Answer is A

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results. Which response is best for the nurse to provide?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

Which client assessment should the nurse perform during nasopharyngeal suctioning?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

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?

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?