A nurse assesses the client and determines the client is at risk for unstable blood glucose. Which activity best reflects the planning phase of the nursing process?

The nurse demonstrates to the client how to perform a blood glucose test using the glucometer.

The nurse formulates a goal of "The client will have a blood sugar between 120-180 for the entire shift

The nurse administers the ordered subcutaneous injection of insulin to the client.

The nurse uses a glucometer to check the client's blood glucose level via a finger stick.

Answer and Explanation

The Correct Answer is B

This action reflects the planning phase of the nursing process, where the nurse sets measurable and achievable goals based on the client's assessment data.

Here’s how the other options fall into different phases:

A. Demonstrating how to perform a blood glucose test = Implementation (teaching/intervention).

C. Administering insulin = Implementation (carrying out an intervention).

D. Checking blood glucose level = Assessment (gathering data).

Nursing Test Bank

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Correct Answer is D

Explanation

A) The ammonia level has decreased each day starting the lactulose: While a decrease in ammonia levels is an important indicator of improvement in hepatic encephalopathy, it is not the best assessment of the therapeutic response to lactulose. The goal of lactulose therapy is to reduce ammonia levels, but the most direct evaluation of therapeutic effect is related to the client's mental status, not just laboratory results.

B) The liver enzymes AST and ALT have decreased to normal levels: Liver enzyme levels such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are important indicators of liver function, but they do not directly reflect the effectiveness of lactulose in treating hepatic encephalopathy. These enzymes may improve as liver function improves, but they are not the most immediate or specific indicator of lactulose’s therapeutic effect.

C) The client is having 5-6 soft, non-formed stools each day: Lactulose works by drawing water into the bowel to promote stool softening and increase bowel movements, which can help lower ammonia levels in the body. While frequent soft stools can be an effect of lactulose, this is not the best measure of therapeutic response in hepatic encephalopathy. The primary goal is improvement in the client's mental status, not just bowel function.

D) The client is awake, alert, and oriented to their environment: The best assessment of the therapeutic response to lactulose is the improvement in the client’s mental status. Lactulose works by reducing the absorption of ammonia from the gastrointestinal tract, which is responsible for the cognitive impairments seen in hepatic encephalopathy. If the client is awake, alert, and oriented, this indicates that lactulose is effectively reducing the ammonia levels and improving the neurological status of the client, making it the most appropriate assessment.

A. Low albumin B. Renal disease C. Hepatic disease D. An elevated gastric pH

Correct Answer is A

Explanation

A) Low albumin: This factor has the most impact on the pharmacokinetic phase of distribution. Albumin is a key protein in the blood that binds to many medications. When albumin levels are low, fewer drug molecules will be bound, leading to an increased concentration of free (unbound) drug in the bloodstream. This can result in enhanced drug effects or toxicity, as the unbound drug is pharmacologically active and more readily able to cross cell membranes.

B) Renal disease: While renal disease can impact drug elimination and excretion, it does not have as direct an effect on the distribution phase of pharmacokinetics. Renal function primarily affects the clearance of drugs from the body rather than how the drug is distributed within the tissues.

C) Hepatic disease: Hepatic disease can affect the metabolism of drugs and their clearance, but it does not directly affect the distribution phase. While the liver is involved in metabolizing drugs, it is the ability to clear or process the drug that is most influenced, rather than its distribution to tissues.

D) An elevated gastric pH: Elevated gastric pH (which can occur with antacid use or in certain conditions) can affect the absorption of some medications but has minimal direct impact on the distribution phase of pharmacokinetics. Distribution is primarily concerned with how a drug moves from the bloodstream into tissues, and this is more influenced by factors like blood flow, protein binding, and the drug's lipophilicity, rather than the pH of the stomach.

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A nurse assesses the client and determines the client is at risk for unstable blood glucose. Which activity best reflects the planning phase of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for client with liver failure admitted with hepatic encephalopathy, Lactulose is ordered Q2 hours. What assessment finding should the nurse use to best evaluate therapeutic response of the medication?

Correct Answer is D

Explanation

What factor has the most impact on the pharmacokinetic phase of distribution?

Correct Answer is A

Explanation

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