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) "I will wash the inhaler once a week with running warm water.": This statement is accurate. It is important to wash the inhaler, especially the mouthpiece, at least once a week to prevent the build-up of medication residue and ensure proper function. The recommendation of using warm water is appropriate, and washing weekly is commonly advised by healthcare providers.
B) "I will administer the second puff 1 minute following the first puff.": This is correct. When using a metered-dose inhaler, it is recommended to wait about 1 minute between puffs to allow the medication to be inhaled properly and for the first dose to be fully delivered before administering the second dose. This ensures that each dose is effective.
C) "I will rinse my mouth with water or mouthwash after inhaler use.": This is a correct statement, particularly for inhaled corticosteroids. Rinsing the mouth after using an inhaler helps prevent the development of oral thrush and other side effects such as irritation or infection. It’s also a good habit to remove any leftover medication from the mouth.
D) "I will take slow deep breaths while activating the inhaler.": This statement indicates the need for additional education. The correct technique involves inhaling slowly and deeply after activating the inhaler, not while activating it. If the client exhales forcefully while pressing the inhaler, they may not be able to inhale the medication effectively. It is crucial that the client activates the inhaler and then takes a slow, deep breath to ensure the medication is delivered properly into the lungs.
Correct Answer is A
Explanation
A) 1 x soft bowel movement: This is the correct answer. Psyllium is a bulk-forming laxative that helps to relieve constipation by absorbing water into the stool, making it easier to pass. A therapeutic effect of psyllium would be the client experiencing a soft bowel movement, indicating the medication has helped to regulate the client's bowel movements and relieve constipation.
B) Gastric pH 2 (Normal pH: 1-4): While this is a normal gastric pH range, it is not related to the therapeutic effect of psyllium. Psyllium works in the gastrointestinal tract to promote bowel regularity, not to alter gastric pH. The pH measurement of gastric contents is not a relevant indicator of the medication's effectiveness.
C) 500 ml of urine output: This finding is not related to the therapeutic effect of psyllium. Psyllium is intended to address bowel function, not urine output. Adequate urine output should be monitored, but it is not the expected outcome for a patient taking psyllium.
D) Blood glucose: 95 (Normal Fasting Blood Glucose: 60-120): While a normal blood glucose level is important, it is not relevant to the action of psyllium. Psyllium does not have a direct effect on blood glucose levels, so a normal blood glucose result is not indicative of a therapeutic effect of the medication.
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