The nurse is developing a plan of care for an older adult client with type 2 diabetes mellitus who reports blurred vision. Which outcome should the nurse include in the plan of care?

Reference Range:

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Hemoglobin A1C [Good diabetic control is less than 7%]

The client's hemoglobin A1C will be less than 7% in 6 months.

The client will self administer all prescribed medications as directed.

The client will keep a detailed diary of food consumed each day.

The client's random fasting glucose will be less than 140 mg/dL (7.77 mmol/L).

Answer and Explanation

The Correct Answer is A

A. Including an outcome that the client’s hemoglobin A1C will be less than 7% in 6 months is correct because hemoglobin A1C reflects long-term glycemic control over 2 to 3 months and is strongly correlated with the prevention of diabetes complications, including blurred vision from diabetic retinopathy. This is a measurable, realistic, and clinically meaningful outcome that directly addresses the client’s current concern.

B. Ensuring that the client self-administers medications as directed is important for overall diabetes management, but it is a process-oriented intervention rather than a clinical outcome. While adherence supports glycemic control, it does not directly measure improvement in blood glucose or risk reduction for complications like blurred vision.

C. Keeping a detailed food diary is a helpful self-management strategy, but it is a behavioral activity, not a specific measurable clinical outcome. It supports education and awareness of dietary patterns but does not directly demonstrate improved glycemic control or resolution of blurred vision.

D. Aiming for a random fasting glucose less than 140 mg/dL is partially correct, but fasting or random glucose measurements fluctuate daily and reflect short-term control. Unlike hemoglobin A1C, this measurement does not provide a comprehensive view of long-term glycemic management and is less useful as a primary outcome for preventing chronic complications.

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Correct Answer is ["C","D"]

Explanation

A. Weight remaining unchanged is not the most appropriate outcome. In clients with fluid overload or heart failure, the goal is to monitor for weight changes to assess fluid balance. The expected outcome might be weight reduction or stabilization depending on therapy, rather than simply remaining unchanged.

B. Oxygen demands increasing is undesirable. The client’s goal is to improve oxygenation and reduce respiratory distress, so increasing oxygen demand would indicate worsening condition rather than improvement.

C. Urine output increasing is an appropriate outcome. Diuretics are commonly used to treat fluid overload in clients with heart failure. Increased urine output indicates effective diuresis, improved fluid balance, and renal perfusion, which are signs of positive therapeutic response. Monitoring urine output helps the nurse evaluate the effectiveness of treatment and detect early complications.

D. BNP (B-type natriuretic peptide) levels decreasing is another appropriate outcome. BNP is released by the ventricles in response to increased pressure and volume overload. Elevated BNP indicates cardiac stress and heart failure. A decrease in BNP reflects improved ventricular function and reduced fluid overload, demonstrating that interventions such as diuretics, ACE inhibitors, or other heart failure treatments are effective.

E. Lung sounds remaining unchanged is not a desirable outcome if the client presents with abnormal findings such as crackles or wheezes. The goal of therapy is usually to improve lung sounds by reducing pulmonary congestion and edema.

F. Potassium levels decreasing is not an appropriate outcome because hypokalemia can result from diuretic therapy and may lead to dangerous cardiac arrhythmias. The desired outcome is maintaining potassium within a safe range.

A. Encourage intake of high potassium foods. B. Initiate toileting schedule. C. Monitor for signs of anemia. D. Provide perineal skin barrier cream.

Correct Answer is C

Explanation

A. Encouraging intake of high potassium foods is contraindicated. Anuric clients cannot excrete potassium effectively, which puts them at risk for hyperkalemia, a potentially life-threatening condition that can cause cardiac arrhythmias or cardiac arrest. Dietary potassium must be restricted, and blood potassium levels closely monitored, particularly in the days between dialysis sessions.

B. Initiating a toileting schedule is unnecessary for an anuric client. Since the client does not produce urine, interventions related to bladder management, such as scheduled voiding, are irrelevant. Nursing care should focus on other physiological and systemic needs.

C. Monitoring for signs of anemia is a priority. CKD leads to reduced production of erythropoietin by the kidneys, which decreases red blood cell production. Signs of anemia include fatigue, pallor, shortness of breath, tachycardia, and decreased activity tolerance. Early identification allows timely interventions such as erythropoiesis-stimulating agents (ESAs), iron supplementation, or blood transfusions. Anemia also affects quality of life and overall functional status in long-term care residents.

D. Providing perineal skin barrier cream is generally for clients who are incontinent. While maintaining skin integrity is important, this intervention is not a priority for an anuric client with no urine output. Resources and interventions should focus on more relevant complications of CKD, such as anemia, electrolyte imbalances, and cardiovascular issues.

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Naxlex Comprehensive Predictor Exams

Patient Data The nurse has received initial prescriptions for the client and is planning nursing care. Select 2 outcomes that would be appropriate for the nurse to include for this client's plan of care.

Correct Answer is ["C","D"]

Explanation

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Correct Answer is C

Explanation

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