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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Polyethylene Glycol: Polyethylene glycol is a medication typically used to treat constipation by promoting bowel movements. While it can be useful in managing constipation, it is not commonly prescribed after a myocardial infarction. In this situation, the focus is more on medications that promote heart health, reduce cardiac workload, and prevent complications related to the heart attack.
B) Bisacodyl: Bisacodyl is a stimulant laxative used to relieve constipation. However, this medication is not typically prescribed immediately following a myocardial infarction. Stimulant laxatives can cause dehydration and excessive fluid shifts, which can be harmful to a client recovering from a heart attack. The focus would be on safer options for bowel management in this context.
C) Senna: Senna is also a stimulant laxative, used for relieving constipation. Similar to bisacodyl, it is not ideal for clients who have recently experienced a myocardial infarction due to its potential for causing dehydration and electrolyte imbalances, which could negatively affect heart function. A gentler approach to bowel management is preferred for these clients.
D) Docusate Sodium: Docusate sodium is a stool softener commonly prescribed to prevent constipation, especially in clients who have recently had a myocardial infarction. After a heart attack, it's important to avoid straining during bowel movements, as this could increase pressure on the heart. Docusate sodium helps soften stools and promotes smoother bowel movements without stimulating the gastrointestinal system in a way that would elevate cardiac stress. It is the most appropriate choice for this client.
Correct Answer is ["20"]
Explanation
Identify the total units of heparin in the bag:
The IV bag contains 25,000 units of heparin in 250 mL.
Identify the desired hourly dose:
The client is ordered to receive 2,000 units of heparin per hour.
Calculate the mL containing 2,000 units:
We can set up a proportion:
(25,000 units) / (250 mL) = (2,000 units) / (x mL)
Solving for x, we get:
x = (2,000 units x 250 mL) / 25,000 units x = 20 mL
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